ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 9
A nurse is conducting a nursing health history. Which component will the nurse address?
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, the nurse focuses on gathering information about the patient's health concerns, medical history, lifestyle, and expectations for their care. Addressing patient expectations is crucial for providing patient-centered care and establishing a therapeutic relationship. The other choices are incorrect because: A: Nurse's concerns are not the primary focus of a nursing health history. C: Current treatment orders are important but are typically addressed during a physical assessment or when implementing care. D: Nurse's goals for the patient are important but should be developed in collaboration with the patient based on their needs and preferences.
Question 2 of 9
A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
Correct Answer: B
Rationale: The correct answer is B: "Keep the stoma dry." Keeping the stoma dry helps prevent infection and skin irritation. Moisture can lead to fungal growth and skin breakdown. Option A is incorrect because keeping the stoma uncovered can increase the risk of contamination and infection. Option C is incorrect as self-care promotes independence and allows the client to become familiar with the procedure. Option D is incorrect as moisture can lead to skin issues.
Question 3 of 9
A client who suffered a vehicular accident a few days ago is in skeletal traction. Which nursing action would BESt promote INDEPENDENCE for this patient?
Correct Answer: B
Rationale: The correct answer is B because encouraging the patient to do leg exercises within the limits of his traction promotes independence by maintaining muscle strength and mobility. This helps prevent muscle atrophy and promotes circulation. Choice A focuses on pain management but does not directly promote independence. Choice C provides assistance but does not actively involve the patient in self-care. Choice D is important for overall care but does not directly promote independence through active patient involvement.
Question 4 of 9
If a patient has elevated pulmonary vascular pressures, the nurse understands that the patient is most likely to develop which of the ff. physiological cardiac changes?
Correct Answer: D
Rationale: The correct answer is D: Right ventricular hypertrophy. Elevated pulmonary vascular pressures lead to increased resistance in the pulmonary circulation, causing the right ventricle to work harder to pump blood to the lungs. Over time, this can result in hypertrophy of the right ventricle as it adapts to the increased workload. Left atrial atrophy (A) and right atrial atrophy (C) are unlikely as the atria are not directly affected by elevated pulmonary pressures. Left ventricular hypertrophy (B) is not the correct choice as it typically occurs in response to systemic hypertension, not pulmonary hypertension.
Question 5 of 9
Which of the ff. problems during the immediate postoperative course ff. lumbar microdiskectomy should be reported to the physician immediately?
Correct Answer: B
Rationale: The correct answer is B because the inability to move the affected leg post lumbar microdiskectomy could indicate a serious complication like nerve damage or blood clot. This would require immediate medical attention to prevent further complications. Incisional pain (A) is common and can be managed with pain medication. A two-inch area of bleeding on the dressing (C) is concerning but can be managed with proper wound care unless it is excessive. Muscle spasm (D) is also common postoperatively and can be managed with medications or physical therapy.
Question 6 of 9
The spouse of a client with gastric cancer expresses concern that the couple’s children may develop this type of cancer when they’re older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
Correct Answer: A
Rationale: The correct answer is A: Type A. Individuals with blood type A have a slightly higher risk of developing gastric cancer compared to other blood types. This is due to the presence of certain antigens associated with Type A blood that may increase susceptibility to gastric cancer. In this case, the nurse mentions a 10% increased risk for individuals with Type A blood, which aligns with the known epidemiological data. Choice B: Type AB is incorrect because individuals with Type AB blood do not have a known increased risk of gastric cancer. Choice C: Type B is incorrect because individuals with Type B blood do not have a known increased risk of gastric cancer. Choice D: Type O is incorrect because individuals with Type O blood actually have a slightly lower risk of developing gastric cancer compared to individuals with Type A blood.
Question 7 of 9
A 62-year old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She’s fatigued from lack of sleep; urinates frequently, even during the night, and has lost weight recently. Tests reveal the following: sodium level 152mEq/L, osmolarity 340mOsm/L, glucose level 125mg/dl, and potassium level of 3.8mEq/L. Which of the following nursing diagnoses is most appropriate for this client?
Correct Answer: C
Rationale: The most appropriate nursing diagnosis for this client is C: Deficient fluid volume related to osmotic diuresis induced by hypernatremia. The client's elevated sodium level of 152mEq/L indicates hypernatremia, which leads to osmotic diuresis and subsequent fluid loss. This results in deficient fluid volume, causing the client to urinate frequently and experience fatigue from lack of sleep. The other choices are incorrect because: A: Deficient fluid volume related to inability to conserve water is not the most appropriate diagnosis as the primary issue is the osmotic diuresis induced by hypernatremia, not the client's inability to conserve water. B: Imbalanced nutrition: Less than body requirements related to hypermetabolic state is not the most appropriate diagnosis as the client's weight loss is likely due to fluid loss from osmotic diuresis, not a hypermetabolic state. D: Imbalanced nutrition: Less than body requirements related to catab
Question 8 of 9
Mr. Reyes has a possible skull fracture. The nurse should:
Correct Answer: A
Rationale: The correct answer is A because signs of brain injury, such as altered level of consciousness, unequal pupil size, and clear fluid draining from the nose or ears, indicate a need for urgent medical attention. Choice B is incorrect because hemorrhaging from the oral cavity is not a common sign of a skull fracture. Choice C is incorrect as elevating the foot of the bed is not appropriate for a skull fracture but may be done for shock. Choice D is incorrect because decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.
Question 9 of 9
Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
Correct Answer: C
Rationale: Step 1: Mr. Franco's condition suggests he may need support and positioning. Step 2: Sandbags provide stability and trochanter rolls prevent hip rotation. Step 3: These help prevent pressure ulcers and maintain proper body alignment. Step 4: Hand bell and bed linen are not essential for Mr. Franco's immediate care. Step 5: Footboard and splint may not be relevant to his specific condition. Step 6: Suction machine and gloves are important but not as crucial as positioning aids for Mr. Franco. Summary: Choice C is correct as it directly addresses Mr. Franco's needs for support and positioning, while the other choices are less relevant or not as essential in this context.