ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?
Correct Answer: B
Rationale: The correct answer is B because involving the client and family in developing outcomes promotes patient-centered care and increases the likelihood of achieving successful outcomes. This approach fosters collaboration, shared decision-making, and empowers the client and family in their own care. It also helps to ensure that the outcomes align with the client's values, preferences, and goals. Choices A, C, and D are incorrect because focusing solely on nursing goals without considering the client's perspective may lead to a lack of engagement and poor outcomes. Discouraging input from other healthcare providers limits the interdisciplinary approach to care, and focusing on why the nurse believes the outcome is important neglects the client's role in the decision-making process.
Question 2 of 5
A client is undergoing peritoneal dialysis. Which of the ff is a major complication of the procedure that the nurse should monitor for?
Correct Answer: D
Rationale: The correct answer is D: Peritonitis. Peritonitis is a major complication of peritoneal dialysis due to infection of the peritoneum. It can lead to serious consequences if not treated promptly. The nurse should monitor for signs of peritonitis such as abdominal pain, cloudy dialysate, fever, and increased white blood cell count. Internal hemorrhage (A), hydronephrosis (B), and ecchymosis (C) are not major complications specific to peritoneal dialysis. Internal hemorrhage can occur but is less common. Hydronephrosis is more related to obstruction of the ureters. Ecchymosis refers to bruising and is not directly associated with peritoneal dialysis.
Question 3 of 5
A 23 y.o. woman is seen at an outpatient clinic for a routine Pap smear. When questioned, she states she is deciding whether to engage in sexual activity with a man she is just getting to know. She asks how she can tell if he has an STD. Which response by the nurse is best?
Correct Answer: D
Rationale: Step 1: The correct answer is D because it emphasizes the importance of medical examination and diagnostic testing to determine if the man has an STD. Step 2: Visual inspection (choice B) is not reliable as some STDs may not present with visible symptoms. Step 3: Relying solely on appearance and condom use (choices A and C) does not guarantee protection against all STDs. Step 4: Choice D is the best option as it advocates for seeking professional medical advice for accurate diagnosis and treatment.
Question 4 of 5
One of the dangers of treating hypernatremia is:
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. Hypernatremia is an elevated sodium level in the blood, which can lead to osmotic shifts causing water to move out of cells, including brain cells. This can result in cerebral edema, potentially leading to neurological complications. Incorrect choices: A: Red blood cell crenation - This occurs in hypertonic solutions, not hypernatremia. C: Red blood cell hydrolysis - Hypernatremia doesn't directly cause red blood cell hydrolysis. D: Renal shutdown - Hypernatremia can stress the kidneys, but it doesn't typically lead to renal shutdown.
Question 5 of 5
When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?
Correct Answer: C
Rationale: The correct answer is C: Weak, slow pulse. Circulatory overload typically presents with signs of fluid volume excess, such as moist gurgling respirations, distended neck veins, dyspnea, and coughing. A weak, slow pulse is not a characteristic sign of circulatory overload, as the heart rate may actually be elevated due to the increased fluid volume. Therefore, a weak, slow pulse would not be likely to occur in this scenario.