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
A client with neuromuscular disorder is receiving intensive nursing care. The client is likely to face the risk for impaired skin integrity. Which of the ff must the nurse ensure to prevent skin breakdown in the client?
Correct Answer: B
Rationale: The correct answer is B: Use pressure relieving devices when the client is in bed. This is because pressure ulcers are a common risk for individuals with neuromuscular disorders due to immobility. Pressure relieving devices such as special mattresses or cushions help redistribute pressure and prevent skin breakdown. Incorrect choices: A: Preventing strenuous exercises is not directly related to preventing skin breakdown in this case. C: Placing the client in Fowler's position may be beneficial for respiratory issues but does not directly address skin integrity. D: Avoiding daily baths with soaps may lead to poor hygiene and does not specifically address the risk of skin breakdown.
Question 3 of 5
Which of the following is the most critical intervention needed for a client with myxedema coma?
Correct Answer: A
Rationale: The correct answer is A: Administering an oral dose of levothyroxine (Synthroid). In myxedema coma, there is severe hypothyroidism leading to altered mental status, hypothermia, and organ failure. Administering levothyroxine is crucial to replace the deficient thyroid hormone rapidly and restore metabolic function. Warming the client (B) is important but secondary to addressing the underlying hormonal imbalance. Measuring intake and output (C) is essential for overall assessment but not the most critical intervention. Maintaining a patent airway (D) is always important in any medical emergency but does not directly address the primary issue of hypothyroidism in myxedema coma.
Question 4 of 5
A client with advanced liver cancer is scheduled for chemotherapy. As part of the chemotherapy regimen, the nurse expects the physician to prescribe:
Correct Answer: B
Rationale: The correct answer is B: Fluorouracil (5-fluorouracil, 5-FU). Fluorouracil is a commonly used chemotherapy drug for treating advanced liver cancer. It works by inhibiting the growth of cancer cells. This drug is specifically effective in targeting rapidly dividing cells, which is a characteristic of cancer cells. Fluorouracil is often used in combination with other chemotherapy drugs to improve treatment outcomes. Summary of other choices: A: Fluoxymesterone (Halotestin) - This is an androgen hormone used to treat certain types of breast cancer, not liver cancer. C: Tamoxifen (Nolvadex) - This is a hormonal therapy drug used in breast cancer, not liver cancer. D: Megestrol (Megace) - This is a hormonal therapy drug used for certain types of cancers, but not typically for liver cancer.
Question 5 of 5
The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
Correct Answer: C
Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting the assessment by examining a specific aspect (surgical dressing with drainage) and will likely proceed to gather more detailed information based on the initial findings. This approach involves moving from a broad overview to specific details, which is essential in assessing postoperative patients for complications. A: Gordon’s Functional Health Patterns is a comprehensive assessment framework that covers various aspects of an individual's health, not specifically focusing on the progression from general to specific assessments in this situation. B: Activity-exercise pattern assessment focuses on the patient's activity levels and exercise routines, which is not the primary focus of the scenario described. D: Problem-oriented assessment is a method that involves identifying and addressing specific health issues or concerns, which is not the primary aim of the assessment approach used by the nurse in this scenario.
Similar Questions
Join Our Community Today!
Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for ATI-RN and 3000+ practice questions to help you pass your ATI-RN exam.
Subscribe for Unlimited Access