ATI RN
Nursing Process Practice Questions Questions
Question 1 of 9
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by identifying the patient's main issue or reason for seeking care. This step helps prioritize data collection and guides further assessment and intervention. By focusing on the presenting situation, the nurse can gather relevant information efficiently and address the immediate concern. Incorrect choices: A: Completing questions in chronological order may not be the most effective approach as it does not prioritize the patient's current problem. C: Making accurate interpretations of data comes after data collection and analysis, not as the first step. D: Conducting an observational overview is important, but it should come after focusing on the patient's presenting situation to gather targeted data.
Question 2 of 9
The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body’s normal flora, the nurse must monitor the client for:
Correct Answer: D
Rationale: The correct answer is D: Diarrhea. Antibiotics can disrupt the normal balance of gut bacteria, leading to diarrhea. This occurs due to the overgrowth of harmful bacteria in the intestines. Monitoring for diarrhea is crucial to prevent dehydration and further complications. Platelet dysfunction (A), stomatitis (B), and oliguria/dysuria (C) are not typically associated with the disruption of normal flora by antibiotics. These symptoms are more likely related to other conditions or side effects of medications, making them incorrect choices in this scenario.
Question 3 of 9
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Correct Answer: D
Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.
Question 4 of 9
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
Correct Answer: D
Rationale: The correct answer is D: To help nurses focus on the scope of medical practice. Developing a standard formal nursing diagnosis helps nurses to identify and focus on the patient's specific health issues within the nursing scope of practice. This enables nurses to provide targeted and effective care interventions. A: To form a language that can be encoded only by nurses - This choice is incorrect because the purpose of a nursing diagnosis is not exclusive to nurses and should be comprehensible to all healthcare professionals caring for the patient. B: To distinguish the nurse’s role from the physician’s role - While this distinction is important, the main purpose of developing a nursing diagnosis is to guide nursing interventions based on the patient's nursing care needs, rather than solely differentiating roles. C: To develop clinical judgment based on other’s intuition - This choice is incorrect as clinical judgment should be based on evidence-based practice and critical thinking, rather than solely relying on intuition or others' opinions.
Question 5 of 9
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient's presenting situation. This is the first step in the problem-oriented approach as it helps the nurse understand the immediate issues and prioritize data collection. By focusing on the presenting situation, the nurse can gather relevant information efficiently. A: Completing questions in chronological order may not address the current problem effectively. C: Making accurate interpretations of the data comes after data collection, not as the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to guide what observations are necessary.
Question 6 of 9
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
Correct Answer: C
Rationale: The correct answer is C: Stop the transfusion. Lumbar pain during blood administration could indicate a transfusion reaction, such as a hemolytic reaction or fluid overload. Stopping the transfusion is crucial to prevent further harm to the client. Obtaining vital signs (A) is important but not the priority when a transfusion reaction is suspected. Assessing the pain further (B) may delay necessary intervention. Increasing the flow of normal saline (D) is not indicated and may worsen fluid overload. In this situation, stopping the transfusion is the most appropriate action to ensure client safety.
Question 7 of 9
An adult is on a clear liquid diet. Which food item can be offered/
Correct Answer: C
Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids that do not contain any solid particles, providing easily digestible nutrients. Jello meets these criteria as it is a clear, gelatin-based dessert that melts into a liquid form at room temperature. Rationale: 1. Jello is a clear liquid that does not contain solid particles, making it suitable for a clear liquid diet. 2. Milk (A) and ice cream (D) are not considered clear liquids as they contain fats and proteins, which are not allowed on a clear liquid diet. 3. Orange juice (B) contains pulp and fibers, making it unsuitable for a clear liquid diet. Summary: Jello is the correct choice because it meets the criteria of being a clear liquid without solid particles. Milk, orange juice, and ice cream are not appropriate choices for a clear liquid diet due to their composition.
Question 8 of 9
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B because focusing on the patient's presenting situation is the first step in the problem-oriented approach. This allows the nurse to gather relevant data related to the current health issue, which is crucial for identifying the problem and formulating a care plan. Option A is incorrect as chronological order may not prioritize the most critical data. Option C is incorrect as interpretations come after data collection. Option D is incorrect as observation typically follows data collection and analysis. Focusing on the patient's presenting situation ensures efficient and effective data collection for problem-solving.
Question 9 of 9
Which of the following hormones retains sodium in the body?
Correct Answer: B
Rationale: The correct answer is B: Aldosterone. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and water balance in the body. It acts on the kidneys to increase reabsorption of sodium, leading to water retention and increased blood volume. This helps maintain blood pressure and electrolyte balance. A: Antidiuretic hormone (ADH) mainly acts on the kidneys to increase water reabsorption, not sodium retention. C: Thyroid hormone does not directly influence sodium retention. D: Insulin regulates blood sugar levels by promoting glucose uptake, it does not have a direct role in sodium retention.