ATI RN
Nursing Process Test Questions Questions
Question 1 of 9
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 9
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.
Question 3 of 9
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 4 of 9
Which of the following dietary interventions prevents the precipitation of calcium renal stones?
Correct Answer: C
Rationale: The correct answer is C: High fluid intake. Adequate hydration helps prevent calcium from becoming concentrated in the urine, reducing the risk of calcium stone formation. Increased fiber intake (choice A) may help prevent other types of stones but not specifically calcium stones. Increased protein intake (choice B) can actually increase calcium excretion, potentially increasing the risk of calcium stone formation. Zinc intake (choice D) does not directly impact calcium stone formation. In summary, high fluid intake is crucial for preventing the precipitation of calcium renal stones due to its role in diluting urine and preventing calcium concentration.
Question 5 of 9
During the physical examination of a client for a possible neurologic disorder, how can the nurse examine the client for stiffness and rigidity of the neck?
Correct Answer: B
Rationale: The correct answer is B. To examine stiffness and rigidity of the neck, the nurse should move the client's head and chin toward the chest. This maneuver assesses for resistance and limitation in neck flexion, which can indicate stiffness and rigidity commonly seen in neurologic disorders like meningitis or cervical dystonia. A: Positioning the client flat on the bed for hours does not specifically target neck stiffness and rigidity. C: Asking the client to bend and pick up objects assesses motor function, not neck stiffness. D: Introducing a painful stimulus is not a standard or appropriate method for examining neck stiffness and rigidity.
Question 6 of 9
The dietary practice that will help a client reduce the dietary intake of sodium is
Correct Answer: C
Rationale: The correct answer is C: Avoiding the use of carbonated beverages. Carbonated beverages often have high sodium content, which can contribute to increased sodium intake. By avoiding these beverages, the client can significantly reduce their sodium consumption. Explanation: 1. Carbonated beverages often contain added sodium for flavor enhancement. 2. By avoiding carbonated beverages, the client eliminates a significant source of hidden sodium in their diet. 3. This dietary practice directly targets reducing sodium intake without compromising other nutritional aspects of the diet. Summary of other choices: A: Increasing the use of dairy products - Dairy products do not necessarily impact sodium intake significantly. B: Using an artificial sweetener in coffee - Artificial sweeteners do not contribute to sodium intake. D: Using catsup for cooking and flavoring food - Catsup is high in sodium and would not help in reducing sodium intake.
Question 7 of 9
A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?
Correct Answer: D
Rationale: The correct answer is D: Dependent. In this scenario, the nurse is administering pain medication based on a healthcare provider's prescription, which demonstrates a dependent nursing intervention. The nurse is reliant on the provider's order to carry out this action. Collaborative interventions involve working with other healthcare professionals, independent interventions are actions that nurses can initiate without supervision, and interdependent interventions involve mutual goal-setting and decision-making among healthcare team members.
Question 8 of 9
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
Correct Answer: D
Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.
Question 9 of 9
A client has been diagnosed with renal failure and is admitted for dialysis. Which of the ff is the nurse’s responsibility as the client undergone dialysis?
Correct Answer: C
Rationale: The correct answer is C: Weighing the client before and after the procedure. This is crucial as it helps monitor fluid removal during dialysis, ensuring the process is effective and safe. Weighing helps determine if the correct amount of fluid has been removed. A: Keeping dialysis supplies in a clean area is important for infection control but not a direct responsibility during the procedure. B: Inspecting the catheter insertion site for signs of infection is essential for monitoring the site's health but not a direct responsibility during dialysis. D: Washing hands before and after handling the catheter is a general infection control measure but not specific to the dialysis procedure itself.