ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, “I have been so constipated lately.” How should the nurse respond?
Correct Answer: C
Rationale: The correct answer is C. The nurse should respond by asking, “Do you take anything to help your constipation?” This response shows active listening and gathers more information about the woman’s current management of constipation. It allows the nurse to assess the woman's current treatment regimen and potential underlying causes. Choice A is incorrect as it diverts the conversation to chest problems, which is unrelated to the woman's primary concern of constipation. Choice B is incorrect as it suggests a potentially harmful solution without assessing the woman's current treatment or determining the cause of her constipation. Choice D is incorrect as it generalizes bowel problems with aging without addressing the woman's specific issue or management.
Question 2 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 3 of 5
When preparing a site for venipunctures with alcohol, how long must the area be cleaned?
Correct Answer: D
Rationale: The correct answer is D: 60 seconds. This is because the area must be cleaned for at least 60 seconds to effectively disinfect the skin and reduce the risk of infection during venipuncture. Cleaning for shorter durations (5, 10, or 30 seconds) may not be sufficient to achieve proper disinfection. Thoroughly cleaning the area for a full minute ensures that the alcohol has enough time to kill bacteria and pathogens on the skin, making it safer for the venipuncture procedure. Shorter cleaning times may leave pathogens behind, increasing the risk of contamination and infection.
Question 4 of 5
Which of the following terms indicates that the patient has a hearing loss caused by aging?
Correct Answer: B
Rationale: The correct answer is B: Presbycusis. Presbycusis refers to age-related hearing loss, commonly affecting higher frequencies. As people age, changes in the inner ear structures can lead to hearing loss. Otoplasty (A) is a surgical procedure to correct ear deformities, not related to aging. Otalgia (C) refers to ear pain, not specifically related to aging. Tinnitus (D) is the perception of ringing or buzzing in the ears, which can occur at any age and is not exclusive to age-related hearing loss.
Question 5 of 5
Which of the following intravenous solutions is hypotonic?
Correct Answer: C
Rationale: The correct answer is C: 0.45% saline. This solution is hypotonic because it has a lower osmolarity compared to the intracellular fluid. It contains fewer solutes than the cells, causing water to move into the cells by osmosis, potentially causing them to swell. Normal saline (A) and Ringer's lactate (B) are isotonic solutions, meaning they have a similar osmolarity to the intracellular fluid and do not cause significant water shifts. 5% dextrose in normal saline (D) is a hypertonic solution, containing more solutes than the cells, leading to water movement out of the cells.
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