ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 9
A female client recovers from a serious case of insect bites. What skin related advice must the nurse give to the client and all her family members to prevent the recurrence of the ailment?
Correct Answer: B
Rationale: The correct answer is B: Apply insect repellent to clothing and exposed skin. This advice helps prevent insect bites, reducing the risk of recurrence. Insect repellent creates a barrier against insects, hence minimizing the chances of getting bitten. Other choices are incorrect as they do not directly address the prevention of insect bites. Choice A is vague and does not provide a specific preventive measure. Choice C is incorrect as thick woollen clothing may not necessarily prevent insect bites. Choice D, sunscreen lotion, protects against UV rays, not insect bites.
Question 2 of 9
A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which of the following glands?
Correct Answer: A
Rationale: The correct answer is A: Adrenal cortex. Primary hyperaldosteronism is a condition where the adrenal cortex produces too much aldosterone hormone, leading to hypertension. The adrenal medulla secretes adrenaline and noradrenaline, not aldosterone, making option B incorrect. The pancreas secretes insulin and glucagon, not aldosterone, making option C incorrect. Option D is incorrect because the adrenal cortex is responsible for aldosterone secretion in primary hyperaldosteronism.
Question 3 of 9
The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
Correct Answer: D
Rationale: The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions." Rationale: 1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being. 2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery. 3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient. 4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes. Summary: A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs. B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses. C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.
Question 4 of 9
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: 1. Asking about chief concerns helps to focus the interview on the patient's needs. 2. It demonstrates active listening and empathy. 3. Allows the nurse to prioritize issues and provide appropriate care. 4. Introductions are already done, and ending the interview abruptly or mentioning medication timing is not patient-centered.
Question 5 of 9
Which of the following would indicate that the patient has a normal corneal light reflex?
Correct Answer: D
Rationale: The correct answer is D because a normal corneal light reflex involves light being reflected at the same spot in both eyes. This indicates that both eyes are aligned properly and focusing light in the same direction. Choice A is incorrect because it refers to accommodation, not the corneal light reflex. Choice B is incorrect as convergence is related to eye movement, not the corneal light reflex. Choice C is incorrect as pupil constriction in response to light is known as the pupillary light reflex, not the corneal light reflex.
Question 6 of 9
A patient reports on admission being “very sick” after taking erythromycin in the past. The patient is to receive erythromycin now. Which of the following actions should the nurse take regarding giving the antibiotic?
Correct Answer: B
Rationale: The correct answer is B: Do not give the antibiotic. This is because the patient has a history of being "very sick" after taking erythromycin in the past, indicating a potential allergic reaction or severe adverse effects. The nurse should not administer the antibiotic to prevent harm to the patient. Choice A is incorrect as it can lead to a repeat adverse reaction. Choice C, giving half the dose, still exposes the patient to potential harm. Choice D, discontinuing the antibiotic, is also incorrect as it implies the patient has already started the medication, which should not be the case given the history of adverse effects.
Question 7 of 9
In addition to antibiotics, which of the ff. recommendations can the nurse make to increase comfort in a patient experiencing sinusitis? Choose all answers that are correct. i. Coughing and deep breathing iv. Room humidifier ii. Sinus irrigation v. Percussion and postural drainage iii. Hot moist packs vi. Semi-fowler’s position
Correct Answer: D
Rationale: The correct answer is D: 2, 4, 5, and 6. 1. Room humidifier (choice 2) helps to keep the air moist, which can ease sinus pressure and discomfort. 2. Hot moist packs (choice 4) can provide relief by reducing congestion and promoting sinus drainage. 3. Percussion and postural drainage (choice 5) can help loosen mucus and improve drainage. 4. Semi-fowler's position (choice 6) can also aid in drainage and reduce sinus pressure. Choices A, B, and C are incorrect because they do not include all the recommended interventions that can help increase comfort in a patient with sinusitis. Each of the incorrect choices is missing at least one crucial recommendation that is beneficial for managing sinusitis symptoms.
Question 8 of 9
Which of the following nursing interventions is appropriate after a lumbar puncture?
Correct Answer: A
Rationale: The correct answer is A: Have the patient lie flat for 6 to 8 hours after a lumbar puncture to prevent complications like post-lumbar puncture headache. Lying flat helps maintain CSF pressure and reduce the risk of leakage. B: Keeping the patient from eating or drinking for 4 hours is not necessary after a lumbar puncture. C: Monitoring pedal pulses q4h is irrelevant to post-lumbar puncture care. D: Keeping the head of the bed elevated 30 degrees for 24 hours is not recommended after a lumbar puncture as it may increase the risk of complications.
Question 9 of 9
A client asks the nurse what PSA is. The nurse should reply that is stands for:
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Prostate-specific antigen (PSA) is a protein produced by the prostate gland. It is primarily used to screen for prostate cancer by measuring the levels of PSA in the blood. PSA levels can help detect prostate cancer early. Therefore, choice A is the correct answer as it accurately describes PSA and its primary use. Summary of Incorrect Choices: B: Protein serum antigen is not a commonly known term in healthcare. There is no specific antigen called "protein serum antigen" used to determine protein levels. C: Pneumococcal strep antigen is a bacterial antigen that causes pneumonia, not related to PSA used in prostate cancer screening. D: Papanicolua-specific antigen is not a recognized term. The Papanicolaou test (Pap smear) is used for cervical cancer screening, not a specific antigen like PSA.