ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 9
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 because the "Where is the pain located?" question corresponds to the "P" component in the PQRST assessment, which stands for Provocative/Palliative factors. This question helps identify the specific location of the pain and what triggers or alleviates it. The other choices are incorrect because: - B: "What causes the pain?" corresponds to the "Q" component (Quality of pain), focusing on the characteristics of the pain. - C: "Does it come and go?" corresponds to the "R" component (Region/Radiation of pain), focusing on the pattern and radiation of the pain. - D: "What does the pain feel like?" corresponds to the "S" component (Severity of pain), focusing on the intensity of the pain.
Question 2 of 9
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): A complete blood count (CBC) is used to identify abnormalities in red blood cells, white blood cells, and platelets. Hematocrit (HCT) and hemoglobin (Hb) levels are part of a CBC and indicate the oxygen-carrying capacity of the blood. Abnormally low HCT and Hb levels can signify conditions like anemia, which can impact a client's ability to undergo surgery due to potential complications related to oxygen delivery. Summary of Incorrect Choices: A: Potential hepatic dysfunction is not directly related to a CBC, and BUN/creatinine levels are markers for kidney function, not liver function. B: Low levels of urine constituents are not assessed in a CBC, which focuses on blood components. D: Electrolyte imbalance is not specifically tested in a CBC; it is usually evaluated through separate blood tests. Coagulation factors are not directly measured in a CBC.
Question 3 of 9
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 because the "Where is the pain located?" question corresponds to the "P" component in the PQRST assessment, which stands for Provocative/Palliative factors. This question helps identify the specific location of the pain and what triggers or alleviates it. The other choices are incorrect because: - B: "What causes the pain?" corresponds to the "Q" component (Quality of pain), focusing on the characteristics of the pain. - C: "Does it come and go?" corresponds to the "R" component (Region/Radiation of pain), focusing on the pattern and radiation of the pain. - D: "What does the pain feel like?" corresponds to the "S" component (Severity of pain), focusing on the intensity of the pain.
Question 4 of 9
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 question corresponds to the "P" in PQRST, which stands for Provocation/Palliation. By asking where the pain is located, the nurse is gathering information about what triggers or relieves the pain, aiding in the assessment of the chest pain. The other choices are incorrect because: B: What causes the pain? - This question corresponds to the "Q" in PQRST, which stands for Quality. It focuses on understanding the characteristics of the pain, not the cause. C: Does it come and go? - This question corresponds to the "R" in PQRST, which stands for Radiation. It pertains to whether the pain spreads to other areas, not if it comes and goes. D: What does the pain feel like? - This question corresponds to the "S" in PQRST, which stands for Severity. It relates to the intensity of the pain, not its location.
Question 5 of 9
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 6 of 9
A client is receiving the cell cycle-nonspecific alkylating agent thiotepa (thioplex), 60 mg weekly for 4 weeks by bladder instillation as part of a chemotherapeutic regimen to treat bladder cancer. The client asks the nurse how the drug works. How does thiotepa exert its therapeutic effects?
Correct Answer: C
Rationale: The correct answer is C because thiotepa is a cell cycle-nonspecific alkylating agent that interferes with both DNA replication and RNA transcription. Thiotepa works by cross-linking DNA strands, leading to inhibition of DNA replication and transcription, ultimately causing cell death. This mechanism of action makes it effective against actively dividing cells, such as cancer cells. Choice A is incorrect because thiotepa does not interfere with DNA replication alone. Choice B is incorrect because thiotepa affects both DNA replication and RNA transcription, not just RNA transcription. Choice D is incorrect because thiotepa does not destroy the cell membrane; instead, it acts on the genetic material within the cell.
Question 7 of 9
Which of the ff does the examiner note when auscultating the lungs of a client with pleural effusion?
Correct Answer: D
Rationale: The correct answer is D because pleural effusion is the accumulation of fluid in the pleural space. When auscultating the lungs of a client with pleural effusion, the examiner would note decreased or absent breath sounds over the area where the fluid has accumulated. This is due to the fluid blocking the transmission of sound through the lungs. Pronounced breath sounds (choice A) would not be present due to the fluid obstructing the normal sound transmission. Expiratory wheezes (choice B) are associated with airway obstruction, not fluid accumulation. Friction rub (choice C) is a dry, grating sound heard with inflammation of the pleura, not specifically related to pleural effusion.
Question 8 of 9
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
Correct Answer: D
Rationale: Step 1: Proper positioning helps maintain alignment and prevent deformities in muscles and joints. Step 2: It reduces the risk of contractures by ensuring that Mr. Gabatan's lower extremities are in optimal positions. Step 3: This promotes circulation and reduces pressure on bony prominences. Step 4: Active exercise may exacerbate spasticity, tilt board may not address positioning adequately, and deep massage may not prevent contractures effectively.
Question 9 of 9
A nurse is updating the care plan of a client whose condition has improved. What is the most appropriate step to take?
Correct Answer: A
Rationale: The correct answer is A because when a client's condition improves, resolved nursing diagnoses should be removed from the care plan to reflect the current status accurately. This ensures the care plan remains relevant and effective. Continuing with the existing plan (choice B) may lead to unnecessary interventions. Focusing only on unresolved issues (choice C) overlooks the importance of updating the care plan comprehensively. Delegating the task to another nurse or staff member (choice D) is not appropriate as the nurse updating the care plan should have a thorough understanding of the client's progress and needs.