ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
A nurse is documenting the progress of a client who has been recovering from a myocardial infarction. Which of the following would be most appropriate to include in the evaluation?
Correct Answer: B
Rationale: The correct answer is B because it directly reflects the client's progress in physical activity, a key indicator of recovery post-myocardial infarction. Walking 500 meters without chest pain shows improved cardiovascular function and exercise tolerance. Vital signs and lab results from admission (A) are important for initial assessment but not for ongoing evaluation. Physician notes (C) may provide insights but do not directly measure the client's progress. Medications prescribed (D) are important but do not reflect the client's specific improvement in physical activity.
Question 2 of 5
A woman with pelvic inflammatory disease complains of lower abdominal pain. Which action should the nurse take first?
Correct Answer: B
Rationale: The correct action is to administer antibiotics as ordered first because pelvic inflammatory disease is caused by an infection, usually from sexually transmitted organisms. Administering antibiotics promptly is crucial to prevent further complications and treat the underlying infection. This helps to alleviate the source of the pain. Rating pain severity, administering analgesics, and patient education are important but should come after addressing the infection to prevent worsening of the condition.
Question 3 of 5
Management of the foregoing patient should include:
Correct Answer: D
Rationale: The correct answer is D because a regular diet with extra fruits and green vegetables can provide essential nutrients for overall health, potassium-sparing diuretics can help manage potassium levels in the body, and discontinuing oral magnesium salts can prevent further complications in the patient. Option A focuses on promoting a healthy diet, B addresses specific medication for potassium management, and C avoids potential interactions with magnesium salts. Therefore, all of the measures (A, B, and C) are necessary for comprehensive management of the patient's condition.
Question 4 of 5
The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording
Correct Answer: C
Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice D) is not as reliable as urinary output for assessing fluid status.
Question 5 of 5
Which of the ff points should a nurse include in the teaching plan for clients who have potential for hypovolemia?
Correct Answer: A
Rationale: The correct answer is A: Avoid alcohol and caffeine. Alcohol and caffeine are diuretics that can increase urine output, leading to fluid loss and potential hypovolemia. This step is crucial in preventing further dehydration. Summary of incorrect choices: B: Increasing milk and dairy products can contribute to fluid intake but does not address the prevention of hypovolemia. C: While dried peas and beans can provide nutrients, they do not specifically address fluid intake or prevention of hypovolemia. D: Avoiding table salt or sodium-containing foods may help in reducing fluid retention but does not directly address fluid intake to prevent hypovolemia.