ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 5
A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?
Correct Answer: D
Rationale: The correct answer is D: The client's ability to produce antibodies. This is crucial in assessing immune system disorders as antibodies play a key role in fighting infections and other foreign invaders. By evaluating the client's ability to produce antibodies, the nurse can determine if the immune system is functioning properly. A: The client's diet is not directly related to immune system disorders unless there are specific deficiencies impacting immune function. B: The client's family member's history of chronic diseases may provide some genetic predisposition information but does not directly assess the client's immune system. C: The client's drug history is important but more relevant to medication interactions and side effects rather than evaluating the immune system.
Question 2 of 5
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should:
Correct Answer: B
Rationale: The correct answer is B: Wear gloves when providing mouth care. This is because standard precautions for AIDS include wearing gloves when in contact with bodily fluids, such as saliva during mouth care. Maintaining strict isolation (A) is not necessary as AIDS is not transmitted through casual contact. Keeping the client in a private room (C) is not required unless the client has an airborne infection. Wearing a gown when delivering food tray (D) is not necessary for standard precautions unless there is a risk of contamination with bodily fluids.
Question 3 of 5
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
Correct Answer: A
Rationale: The correct answer is A: Platelet count, prothrombin time, and partial thromboplastin time. These parameters are essential in monitoring DIC because platelet count reflects the risk of bleeding, while prolonged prothrombin time and partial thromboplastin time indicate impaired clotting function, which is characteristic of DIC. Explanation for why other choices are incorrect: - Choice B: Blood glucose levels and WBC count are not specific indicators for DIC monitoring. - Choice C: Thrombin time, calcium levels, and potassium levels do not directly assess clotting abnormalities associated with DIC. - Choice D: While fibrinogen level is important in DIC, WBC count alone is not a specific indicator for monitoring DIC.
Question 4 of 5
During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:
Correct Answer: B
Rationale: The correct answer is B: Stool for Clostridium difficile test. In this scenario, the client is experiencing symptoms suggestive of a possible Clostridium difficile infection, a common complication of chemotherapy. The test is crucial to confirm the presence of C. difficile toxins in the stool, which would guide appropriate treatment with antibiotics such as metronidazole or vancomycin. A: Enzyme-linked immunosuppressant assay is not relevant in this context as it is used to measure levels of immunosuppressant drugs, not for diagnosing C. difficile infection. C: Flat palate X-ray of the abdomen is unnecessary and would not provide information about the cause of the symptoms. D: Electrolyte panel and hemogram are important for monitoring overall health status but do not directly address the specific issue of possible C. difficile infection.
Question 5 of 5
A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
Correct Answer: A
Rationale: The correct answer is A: A-positive blood to an A-negative client. This is because in ABO blood typing, individuals with blood type A have anti-B antibodies in their plasma. Therefore, if A-positive blood (which contains the A antigen) is given to an A-negative client (who has anti-A antibodies), there is a high risk of an acute hemolytic reaction due to the antibodies attacking the transfused blood cells. Choices B, C, and D are incorrect because they do not involve a mismatch of ABO blood types that would lead to a significant risk of acute hemolytic reaction. In choice B, O-positive blood can be safely transfused to an A-positive client as O blood is considered the universal donor. In choice C, O-negative blood can be safely given to an O-positive client as O-negative blood is compatible with all blood types. In choice D, B-positive blood can be safely administered to an AB-positive client as the AB blood type can receive both