ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? This matches with the "Location" component of the PQRST. This question helps determine the specific area where the pain is occurring, providing crucial information for diagnosis and treatment. This step is important in identifying potential underlying issues related to the pain. Summary of other choices: B: What causes the pain? - This question relates to the "Provocation/Palliation" component, not the location. C: Does it come and go? - This question corresponds to the "Quality" component, focusing on the characteristics of the pain. D: What does the pain feel like? - This question aligns with the "Severity" component, concentrating on the intensity of the pain.
Question 2 of 5
A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)
Correct Answer: C
Rationale: Step 1: Repositioning a patient who is on bed rest is a nursing intervention as it involves direct patient care to prevent complications like pressure ulcers. Step 2: Nursing interventions aim to promote patient health, prevent illness, and provide comfort. Step 3: Ordering chest x-ray and prescribing antibiotics are medical interventions, beyond the scope of nursing practice. Step 4: Teaching preoperative exercises falls under nursing education but not a direct nursing intervention involving patient care. Summary: Choice C is correct as it aligns with the essence of nursing interventions focusing on patient care and wellbeing. Choices A, B, and D involve actions that are not within the scope of nursing interventions.
Question 3 of 5
According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
Correct Answer: D
Rationale: The correct answer is D: Risk for body image disturbance. In Maslow's hierarchy, physiological needs like airway clearance take precedence over emotional or self-esteem needs like body image disturbance. Priority is given to addressing life-threatening issues first. Impaired urinary elimination could be related to the client's heart failure and should be addressed to prevent complications. Coping mechanisms are important for emotional well-being but are not as critical as physiological needs in this scenario.
Question 4 of 5
A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client’s priorities for care using which of the following?
Correct Answer: A
Rationale: The correct answer is A, assessment skills. Assessing the client's current condition, including respiratory status, is crucial in determining priorities for care in asthma management. By utilizing assessment skills, the nurse can gather essential information to identify the client's immediate needs and develop an individualized care plan. Nursing books (B) can provide general information but do not provide real-time data on the client's current status. Client's records (C) may contain historical information but may not reflect the client's current condition. Supervisor's advice (D) is important but should supplement rather than replace the nurse's assessment skills in determining immediate care priorities.
Question 5 of 5
A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client’s urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?
Correct Answer: D
Rationale: The correct answer is D: Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large volumes of dilute urine. This results in low urine osmolality as the kidneys are unable to concentrate the urine. On the other hand, the serum osmolality increases due to the lack of ADH causing water retention. Therefore, the laboratory findings of low urine osmolality and high serum osmolality support the diagnosis of diabetes insipidus. Explanation for other choices: A: Above-normal urine and serum osmolality levels - This does not align with the pathophysiology of diabetes insipidus. B: Below-normal urine and serum osmolality levels - This is incorrect as low serum osmolality is not characteristic of diabetes insipidus. C: Above-normal urine osmolality level, below-normal
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