ATI RN
Nursing Process Test Questions Questions
Question 1 of 5
A hospitalized client has the following blood lab values: WBC 3,000/ul, RBC 5.0 (X 106), platelets 300, 000, what would be a priority nursing intervention?
Correct Answer: A
Rationale: The correct answer is A: Preventing infection. With a low WBC count of 3,000/ul, the client is at high risk for infection due to compromised immune function. Priority is to prevent infection by implementing strict infection control measures, such as hand hygiene, sterile techniques, and isolation precautions. Alleviating pain (B) would be important but not the priority in this case. Controlling infection (C) is similar to preventing infection and would be a secondary intervention. Monitoring blood transfusion reactions (D) is not relevant to the client's current lab values.
Question 2 of 5
Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?
Correct Answer: D
Rationale: The correct answer is D: Obtaining baseline vital signs before administering the first dose. This intervention is crucial to establish the client's baseline condition before starting morphine therapy. Baseline vital signs provide a comparison for monitoring the client's response to the medication and detecting any adverse effects. This step ensures the nurse can identify and address any potential complications promptly. Other choices are incorrect: A: Assisting with a naloxone challenge test before therapy begins - Naloxone challenge test is used to diagnose opioid dependence, not appropriate for monitoring pain management. B: Discontinuing the drug immediately if signs of dependence appear - Abrupt discontinuation can lead to withdrawal symptoms and should be managed gradually. C: Changing the administration route to P.O. if the client can tolerate fluids - Changing the route of administration should be based on clinical indications, not solely on the client's ability to tolerate fluids.
Question 3 of 5
A client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?
Correct Answer: A
Rationale: The correct answer is A: Surgery. Surgery is the primary treatment for vaginal cancer, especially for early-stage cases. It involves removing the cancerous tissue from the vagina. Radiation (B) and chemotherapy (C) may also be used in addition to surgery in some cases, but they are not the primary treatment. Immunotherapy (D) is not a standard treatment for vaginal cancer. It is important to prioritize surgery as it directly targets and removes the cancerous cells from the affected area, increasing the chances of successful treatment and recovery.
Question 4 of 5
The physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guerin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:
Correct Answer: B
Rationale: The correct answer is B: Hematuria. Bacillus Calmette-Guerin (BCG) is commonly used in the treatment of bladder cancer. It works by stimulating the immune system to attack and destroy cancer cells in the bladder. One of the common side effects of BCG instillations is hematuria, which is the presence of blood in the urine. This can occur due to irritation of the bladder lining by the BCG solution, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware of what to expect during treatment. A: Renal calculi - BCG therapy is not commonly associated with the formation of renal calculi. C: Delayed ejaculation - Delayed ejaculation is not a common side effect of BCG therapy. D: Impotence - Impotence is not a common side effect of BCG therapy.
Question 5 of 5
Before a cancer receiving total parenteral nutrition (TPN) resumes a normal diet, the nurse teaches him about dietary sources of minerals. Which foods are good sources of zinc?
Correct Answer: D
Rationale: The correct answer is D: Whole grains and meats. Zinc is mainly found in animal-based foods like meats and seafood. Meats, particularly red meats, are rich sources of zinc. Whole grains like wheat, rice, and oats also contain zinc. Legumes (Choice C) are sources of other minerals but not high in zinc. Fruits and vegetables (Choices A and B) are not significant sources of zinc. The correct answer provides the best options for the cancer patient to obtain an adequate amount of zinc for recovery.