ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
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 2 of 5
Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
Correct Answer: B
Rationale: Step-by-step rationale for choice B: Footboard and splint: 1. Footboard helps prevent foot drop by maintaining proper alignment and preventing pressure ulcers. 2. Splint helps stabilize and support Franco's limbs to prevent contractures and maintain proper positioning. 3. Both items are essential for Franco's safety, comfort, and prevention of complications. 4. Hand bell and extra bed linen (Choice A) are not crucial for Franco's immediate care needs. 5. Sandbag and trochanter rolls (Choice C) are not directly relevant to Franco's specific conditions. 6. Suction machine and gloves (Choice D) are important for airway management but not the priority for bedside equipment in this case.
Question 3 of 5
The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct: 1. Having intercourse with just the spouse means a monogamous relationship with a trusted partner, minimizing risk of exposure to HIV. 2. It eliminates the risk of contracting HIV from multiple sexual partners. 3. This choice adheres to safer sex practices by reducing the chances of exposure to HIV. 4. This choice also promotes trust and communication within the relationship, further reducing the risk of HIV transmission. Summary: - Choice A is correct as it promotes monogamy and reduces the risk of exposure to HIV. - Choices B, C, and D do not guarantee zero risk of HIV transmission as blood donations, HIV antibodies, and condom use can still pose risks if not used or implemented correctly.
Question 4 of 5
The nurse is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse plan to use to dilute this medication?
Correct Answer: C
Rationale: The correct answer is C: Normal saline solution. Phenytoin is incompatible with dextrose solutions, so options A and D are incorrect. Lactated Ringer's solution contains calcium, which can interact with phenytoin, leading to precipitation. Therefore, option B is also incorrect. Normal saline is the most compatible diluent for phenytoin, maintaining the drug's stability and effectiveness. It is essential to use the appropriate diluent to prevent adverse reactions or drug interactions.
Question 5 of 5
A very popular means of early detection of breast cancer is:
Correct Answer: D
Rationale: The correct answer is D: Breast self-examination. This is because regular breast self-examination allows individuals to become familiar with their own breast tissue and identify any changes or abnormalities early on. X-ray (choice A) and surgical (choice C) are not typically used as early detection methods for breast cancer. Choice B is also incorrect because while mammograms (X-rays) are an important screening tool, self-examination should not be replaced by it, as it is a proactive way for individuals to take charge of their own health.
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