ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
A nurse is updating the care plan of a client whose condition has improved. What is the most appropriate step to take?
Correct Answer: A
Rationale: The correct answer is A because when a client's condition improves, resolved nursing diagnoses should be removed from the care plan to reflect the current status accurately. This ensures the care plan remains relevant and effective. Continuing with the existing plan (choice B) may lead to unnecessary interventions. Focusing only on unresolved issues (choice C) overlooks the importance of updating the care plan comprehensively. Delegating the task to another nurse or staff member (choice D) is not appropriate as the nurse updating the care plan should have a thorough understanding of the client's progress and needs.
Question 2 of 5
. A female client experiences trauma to her urinary tract during an accident. Which of the ff factors should the nurse consider while assessing the client?
Correct Answer: B
Rationale: The correct answer is B: Assessment and recognition of abnormal findings. This is crucial as trauma to the urinary tract can lead to various complications such as urinary retention, infection, or injury to surrounding structures. By assessing and recognizing abnormal findings, the nurse can promptly identify any issues and initiate appropriate interventions. Choice A (Assessment of sexual habits) may be important for assessing risk factors for urinary tract trauma, but it is not directly related to assessing the client's current condition post-accident. Choice C (Assessment of allergies to seafood) is irrelevant in this scenario as it does not impact the assessment of urinary tract trauma. Choice D (Assessment of insurance coverage) is not a priority when assessing a client's immediate health status post-accident.
Question 3 of 5
The lungs regulate acid-base balance b₃y⁻ all of the following except:
Correct Answer: C
Rationale: The correct answer is C: Slowing ventilation. The lungs regulate acid-base balance by controlling carbon dioxide levels through ventilation. Increasing ventilation helps expel excess carbon dioxide, thus regulating pH. Slowing ventilation would lead to CO2 buildup and an imbalance in acid-base levels. Excreting HCO3- into the blood (choice A) helps maintain pH, while increasing ventilation (choice D) aids in removing excess CO2. Therefore, slowing ventilation is the exception as it would disrupt the acid-base balance by not effectively regulating carbon dioxide levels.
Question 4 of 5
A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;
Correct Answer: B
Rationale: To calculate the drip rate, we first need to find the total volume of IV fluid to be administered, which is 1500 ml + 1250 ml = 2750 ml. Then, we multiply the total volume by the drop factor (2750 ml * 15 gtt/ml = 41250 gtt). Finally, we divide the total number of drops by the time in minutes (24 hours * 60 min = 1440 min) to get the drip rate: 41250 gtt / 1440 min = 28.47 gtt/min, which rounds up to 29 gtt/min. Therefore, choice B is correct. Choices A, C, and D are incorrect because they do not reflect the accurate calculation based on the given parameters.
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.