ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
A nurse evaluates a client’s response to a nursing intervention and determines that the expected outcome was not achieved. What is the nurse’s most appropriate action?
Correct Answer: D
Rationale: The correct answer is D: Reassess the client's condition. When an expected outcome is not achieved, the nurse must reassess the client's condition to identify the reasons for the lack of success. This step allows the nurse to gather more information, adjust the plan of care if necessary, and determine the most suitable course of action to help the client achieve the desired outcome. Choice A: Terminating the plan of care is premature without reassessing the client's condition and identifying potential barriers to success. Choice B: Modifying the plan of care may be necessary after reassessment but should not be the first step. Choice C: Reassigning care to another nurse does not address the underlying issues affecting the client's response to the intervention.
Question 2 of 5
A 23 y.o. woman is seen at an outpatient clinic for a routine Pap smear. When questioned, she states she is deciding whether to engage in sexual activity with a man she is just getting to know. She asks how she can tell if he has an STD. Which response by the nurse is best?
Correct Answer: D
Rationale: Step 1: The correct answer is D because it emphasizes the importance of medical examination and diagnostic testing to determine if the man has an STD. Step 2: Visual inspection (choice B) is not reliable as some STDs may not present with visible symptoms. Step 3: Relying solely on appearance and condom use (choices A and C) does not guarantee protection against all STDs. Step 4: Choice D is the best option as it advocates for seeking professional medical advice for accurate diagnosis and treatment.
Question 3 of 5
One of the dangers of treating hypernatremia is:
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. Hypernatremia is an elevated sodium level in the blood, which can lead to osmotic shifts causing water to move out of cells, including brain cells. This can result in cerebral edema, potentially leading to neurological complications. Incorrect choices: A: Red blood cell crenation - This occurs in hypertonic solutions, not hypernatremia. C: Red blood cell hydrolysis - Hypernatremia doesn't directly cause red blood cell hydrolysis. D: Renal shutdown - Hypernatremia can stress the kidneys, but it doesn't typically lead to renal shutdown.
Question 4 of 5
When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?
Correct Answer: C
Rationale: The correct answer is C: Weak, slow pulse. Circulatory overload typically presents with signs of fluid volume excess, such as moist gurgling respirations, distended neck veins, dyspnea, and coughing. A weak, slow pulse is not a characteristic sign of circulatory overload, as the heart rate may actually be elevated due to the increased fluid volume. Therefore, a weak, slow pulse would not be likely to occur in this scenario.
Question 5 of 5
Which of the following is the appropriate nursing diagnosis?
Correct Answer: B
Rationale: The correct answer is B, "Fluid volume deficit R/T uncontrolled vomiting." This option correctly identifies the cause of the fluid volume deficit as uncontrolled vomiting, which is a common reason for fluid loss. The nursing diagnosis should always reflect the underlying cause of the issue. A is incorrect as "furrow tongue" is not a recognized medical term related to fluid volume deficit. C is incorrect because dehydration is not typically related to subnormal body temperature unless it is severe. D is incorrect as incessant vomiting is more specific to the cause, but the term "dehydration" should be used instead of "fluid volume deficit" in this context. In summary, option B is the appropriate nursing diagnosis as it accurately links the fluid volume deficit to the cause of uncontrolled vomiting.