ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
A factory worker suffered a chemical burn to the eye and arrives at the Emergency department. What is the first action of the nurse?
Correct Answer: D
Rationale: The correct answer is D: flush the eye continuously with sterile solution. This is the first action because it helps to remove the chemical from the eye, preventing further damage. Flushing with sterile solution dilutes and washes away the chemical, reducing the risk of ongoing injury. Applying a cold compress (A) may help with pain but does not address the chemical exposure. Applying a bandage (B) can trap the chemical and worsen the injury. Performing an assessment (C) should come after immediate treatment to ensure proper care but should not delay flushing the eye.
Question 2 of 5
A man with a history of diabetes and chronic lung disease is admitted to the hospital with prostate cancer. He has all the following symptoms. Which should the nurse address first?
Correct Answer: C
Rationale: The correct answer is C: Respiratory rate 36/min. In this case, the nurse should address the respiratory rate first due to the patient's chronic lung disease, indicating potential respiratory distress. High respiratory rate may signify hypoxia, infection, or worsening lung function, posing immediate life-threatening risks. Addressing this symptom promptly is crucial to prevent respiratory failure. Fever (A) and difficulty urinating (B) are important but not as urgent as addressing potential respiratory distress. Painful legs and feet (D) may indicate peripheral neuropathy related to diabetes, which is important but not as critical as addressing the respiratory issue.
Question 3 of 5
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Correct Answer: A
Rationale: The correct answer is A because the first phase of the nursing process is assessment, where the nurse gathers comprehensive data about the patient's health status. This step is crucial in identifying problems and setting priorities for care. Choice B comes in the second phase (diagnosis), C in the third phase (planning), and D in the last phase (evaluation). Assessing the patient's condition is the foundation for the rest of the nursing process.
Question 4 of 5
A client has malignant lymphoma. As part of her chemotherapy, the physician prescribes chlorambucil (Leukeran), 10mg by mouth daily. When caring for the client, the nurse teaches her about adverse reactions to chlorambucil, such as alopecia. How soon after the first administration of chorambucil might this reaction occur?
Correct Answer: B
Rationale: The correct answer is B: 2 to 3 weeks. Alopecia is a common adverse reaction to chlorambucil, a type of chemotherapy drug that can cause hair loss. Alopecia typically occurs around 2 to 3 weeks after the first administration of chlorambucil. This is because chemotherapy drugs affect rapidly dividing cells, including hair follicles. Hair loss is a well-known side effect of many chemotherapy drugs, and it is important for the nurse to educate the client about this potential side effect. Incorrect choices: A: Immediately - Hair loss does not occur immediately after the first administration of chlorambucil. C: 1 week - Hair loss typically occurs later than 1 week after starting chemotherapy. D: 1 month - While hair loss can occur within a month, it is more likely to happen sooner, around 2 to 3 weeks after starting the medication.
Question 5 of 5
Which type of neuron transmits impulses from the central nervous system to the muscles and glands?
Correct Answer: C
Rationale: The correct answer is C: Efferent neurons transmit impulses from the central nervous system to muscles and glands. This is because efferent neurons are responsible for carrying motor signals away from the central nervous system to control muscle movement and gland secretion. Afferent neurons (choice A) transmit sensory information from the body to the central nervous system. Affective (choice B) is not a term used in neuroscience for describing neuron functions. Effective (choice D) is not a term used in neuroscience and does not describe the specific function of transmitting impulses from the central nervous system to muscles and glands.
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