ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 9
A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
Correct Answer: A
Rationale: The correct answer is A: Reassess the patient and situation. The nurse should reassess to determine the cause of the pressure ulcer, evaluate the effectiveness of the current turning schedule, and identify any contributing factors. This allows for a more targeted intervention plan. B: Incorrect. Simply increasing the frequency of turning may not address the underlying issue causing the pressure ulcer. C: Incorrect. Delegating turning to nursing assistive personnel without reassessment may not address the root cause of the pressure ulcer. D: Incorrect. Applying medication without reassessment may not address the underlying cause of the pressure ulcer and could potentially worsen the condition.
Question 2 of 9
Which of the ff should a client with auto immune disorder be advised to avoid?
Correct Answer: C
Rationale: The correct answer is C: Being in crowds during the periods of immunosuppression. Clients with autoimmune disorders have compromised immune systems, making them more susceptible to infections. Being in crowds increases the risk of exposure to various pathogens, potentially leading to infections. Avoiding crowds during periods of immunosuppression helps minimize the risk of infections. A: Resting during the periods of severe exacerbation is important for managing symptoms and conserving energy, but it is not specifically related to avoiding triggers for autoimmune disorders. B: Regular exercise during the periods of remission is beneficial for overall health and can help manage autoimmune disorders, as long as it is appropriate and not excessive. D: Humid environments during the periods of remission do not directly impact autoimmune disorders unless the individual has a specific sensitivity to humidity.
Question 3 of 9
A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
Correct Answer: C
Rationale: The correct answer is C: Listen and show interest as the client expresses feelings. It is essential for the nurse to actively listen and show empathy towards the client's emotional distress. This approach demonstrates compassion, understanding, and support for the client during a vulnerable moment, which is crucial for the therapeutic relationship. By actively listening, the nurse can validate the client's emotions and provide a safe space for them to express their feelings. This can help the client feel heard and supported, leading to improved emotional well-being. Choices A, B, and D are incorrect: A: Continuing with the bath and telling the client not to worry dismisses the client's emotions and fails to address their underlying feelings of loneliness and isolation. B: Asking for a psychiatric consultation may not be necessary at this point, as the client's emotional distress can be effectively managed through therapeutic communication. D: Stating that the friends' behavior shows they aren't true friends is judgmental and unhelpful, as it does not address
Question 4 of 9
Which of the following medications can be used to quickly reduce SOB in a crisis situation for a patient with end-stage respiratory disease?
Correct Answer: B
Rationale: Step 1: IV morphine is the correct choice as it is a potent analgesic and has a rapid onset of action to reduce shortness of breath (SOB) in a crisis situation. Step 2: Oral cortisone (A) is not suitable for quick relief of SOB as it has a slower onset of action. Step 3: IM meperidine (C) is an opioid analgesic but not commonly used for managing SOB in end-stage respiratory disease. Step 4: IV propranolol (D) is a beta-blocker and not indicated for immediate relief of SOB in a crisis situation.
Question 5 of 9
Approximately how much fluid is lost in acute weight loss of .5kg?
Correct Answer: C
Rationale: The correct answer is C: 500 ml. When someone loses 0.5 kg of weight, it is estimated that about 500 ml of fluid has been lost, as 1 kg of body weight is roughly equivalent to 1 liter of fluid. This fluid loss is due to water loss through sweating, breathing, and urine. Choice A (50 ml) is too small of an amount for a significant weight loss. Choice B (750 ml) is too high and would correspond to a larger weight loss. Choice D (75 ml) is also too small to account for a 0.5 kg weight loss.
Question 6 of 9
A patient with a new diagnosis of lymphoma is experiencing fatigue. Which of the ff. is the best way to assess her fatigue?
Correct Answer: B
Rationale: The correct answer is B because having the patient rate her fatigue on a scale allows for a subjective assessment directly from the patient, providing valuable insight into the severity and impact of fatigue on her daily life. This approach considers the patient's perspective, which is crucial in understanding her experience and tailoring interventions. Choice A (observing activity level) may not accurately capture the subjective experience of fatigue. Choice C (monitoring vital signs) does not directly assess fatigue but rather general health status. Choice D (monitoring hemoglobin and hematocrit values) can indicate anemia but may not fully capture the patient's fatigue experience.
Question 7 of 9
Which of the ff blood vessel is commonly affected by thrombophlebitis?
Correct Answer: C
Rationale: The correct answer is C, veins deep in the lower extremities, due to stasis and immobility in the legs causing blood to pool and predispose to thrombus formation. This is known as deep vein thrombosis (DVT). Veins deep in the upper extremities (A) are less commonly affected. The popliteal vein of the leg (B) is a common site for DVT, but it is not the most commonly affected. Veins connected to the heart (D) are arteries, not veins, and are not typically involved in thrombophlebitis.
Question 8 of 9
The nurse is preparing to administer a unit of blood to a client’s who’s anemic. After its removal from the refrigerator, the blood should be administered within:
Correct Answer: C
Rationale: The correct answer is C: 2 hours. Blood should be administered within 30 minutes to 4 hours after removal from the refrigerator to prevent bacterial growth and maintain its efficacy. Option C falls within this timeframe, ensuring safety and effectiveness. Option A (1 hour) is too short, while option B (4 hours) and option D (6 hours) exceed the recommended timeframe, increasing the risk of bacterial contamination and compromising the quality of the blood product.
Question 9 of 9
A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
Correct Answer: A
Rationale: The correct answer is A: Reassess the patient and situation. The nurse should reassess to determine the cause of the pressure ulcer, evaluate the effectiveness of the current turning schedule, and identify any contributing factors. This allows for a more targeted intervention plan. B: Incorrect. Simply increasing the frequency of turning may not address the underlying issue causing the pressure ulcer. C: Incorrect. Delegating turning to nursing assistive personnel without reassessment may not address the root cause of the pressure ulcer. D: Incorrect. Applying medication without reassessment may not address the underlying cause of the pressure ulcer and could potentially worsen the condition.