ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 9
A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct: 1. Safety: Morbidly obese patients are at higher risk of falls during transfers. 2. Assistance: Having two other personnel ensures safe transfer. 3. Weight distribution: Distributing the patient's weight among multiple helpers reduces strain. 4. Proper body mechanics: Allows for proper positioning and technique while assisting. Summary of why other choices are incorrect: B. Medication doesn't address the safety concern of transferring a morbidly obese patient. C. Reviewing activity orders is not the immediate action needed for the patient's first bathroom transfer. D. Offering a walker may not provide sufficient support for a morbidly obese patient during the transfer.
Question 2 of 9
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
Correct Answer: A
Rationale: The correct answer is A: Assessment. The nurse made an error in the assessment phase by not communicating the patient's condition promptly. Assessment involves collecting data and recognizing changes in the patient's condition. By not informing the nurse about feeling dizzy and light-headed, the nurse missed crucial information that could have indicated a deteriorating condition. The other choices are incorrect because: B: Diagnosis comes after assessment and involves analyzing data to identify the patient's problems. C: Implementation is the phase where nursing interventions are carried out based on the diagnosis. D: Evaluation is the final phase where the nurse assesses the effectiveness of interventions and outcomes.
Question 3 of 9
What is an important consideration regarding TPN administration?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Aseptic technique prevents infection at IV site. 2. TPN is a high-risk solution, requiring strict aseptic administration. 3. Contaminated site can lead to sepsis or other serious complications. 4. Choice B increases risk of contamination. 5. Choice C increases risk of bacterial growth. 6. Choice D may introduce air or contamination. Summary: Choice A is correct as it emphasizes infection prevention. Choices B, C, and D pose risks of contamination, bacterial growth, or air introduction.
Question 4 of 9
A client with HIV has been prescribed anti viral medications. What instructions related to administration of medications should the nurse give such a client?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Timing: Antiviral medications should be taken as prescribed to maintain consistent drug levels in the body. 2. Around meals: Taking medications with or without food can affect absorption, so timing around meals helps with consistency. 3. Compliance: Following the timing instructions increases medication effectiveness and reduces the risk of drug resistance. Other Choices: B) Avoiding harsh sunlight: Not directly related to medication administration; may be a precaution for other reasons. C) Having medications with fruit juice: This is not a standard instruction for antiviral medications; may not be suitable for all medications. D) Increasing dose for worsening symptoms: This is dangerous and should only be done under healthcare provider supervision; self-adjusting medication doses can be harmful.
Question 5 of 9
The examiner shines a light in the patient’s eyes and notes that the pupils are round and constrict from 4 to 2 mm bilaterally. Next, the examiner asks the patient to focus on a far object, then on the examiner’s finger as it is brought from 3 feet distance to 5 inches distance. The pupils constrict bilaterally and the eyes turn inward. Which of the ff. would be the correct documentation of these findings?
Correct Answer: B
Rationale: The correct answer is B: PERRLA, which stands for Pupils Equal, Round, Reactive to Light, and Accommodation. This documentation reflects a comprehensive assessment of the pupils' response to light and accommodation. The pupils constricting from 4 to 2 mm bilaterally in response to light indicates they are reactive. Additionally, the eyes turning inward when focusing on a near object shows accommodation. Choice A is not the best option because it only mentions the pupil size without capturing other important aspects of the assessment. Choice C is too vague, as it does not specify the exact response of the pupils. Choice D is incorrect because it does not provide a detailed description of the pupils' response to both light and accommodation. Therefore, option B is the most appropriate choice as it encompasses all the necessary components of the assessment.
Question 6 of 9
During the physical assessment, the nurse recalls that the areas most frequently affected by multiple sclerosis are the:
Correct Answer: C
Rationale: Rationale for Choice C (Correct Answer): 1. Multiple sclerosis (MS) commonly affects the optic nerve and chiasm. 2. MS is characterized by demyelination of nerves, leading to visual disturbances. 3. Optic nerve involvement results in vision problems, such as blurred vision. 4. Chiasm involvement can cause visual field deficits and color perception changes. Summary of Other Choices: A: Lateral, 3rd, and 4th ventricles - Incorrect. MS primarily affects the central nervous system, not ventricles. B: Pons, medulla, and cerebral peduncles - Incorrect. While these areas are part of the brainstem, they are not commonly affected in MS. D: Above areas - Incorrect. This choice is vague and does not specify any specific areas affected by MS.
Question 7 of 9
The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
Correct Answer: B
Rationale: The correct answer is B because the patient being able to ambulate in the hallway with crutches indicates that the expected outcome of improved physical mobility due to the fractured leg has been met. This demonstrates progress towards independence and recovery. A is incorrect because the patient still requires assistance, indicating dependency. C is incorrect because denial of pain does not necessarily indicate improved physical mobility. D is incorrect because it is too general and does not directly show achievement of the specific goal related to physical mobility.
Question 8 of 9
A female client with lymphedema expresses her anxiety about the abnormal enlargement of an arm. Which of the ff suggestions should a nurse give to support the clients self image?
Correct Answer: C
Rationale: The correct answer is C: Introduce variations in styles of clothing. This suggestion promotes the client's self-image by helping her feel more comfortable and confident in her appearance despite the lymphedema. It allows her to express her personal style while accommodating the enlarged arm. A: Placing the arm in a sling does not address the client's self-image concerns and may further highlight the abnormality. B: Applying cold soaks may help with swelling but does not directly address the client's self-image. D: Tying a tight bandage can worsen lymphedema and does not address the client's self-image concerns.
Question 9 of 9
Which nursing diagnosis is most appropriate for a client with Addison’s disease?
Correct Answer: C
Rationale: The correct answer is C, Excessive fluid volume. In Addison's disease, there is a deficiency of cortisol and aldosterone leading to sodium loss and water retention. This imbalance can result in excessive fluid volume. A) Risk for infection is not directly related to Addison's disease. B) Urinary retention is not a common symptom of Addison's disease. D) Hypothermia is not a typical manifestation of Addison's disease.