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
Which of the ff must the nurse consider when administering IV fluids to clients with hypertension?
Correct Answer: B
Rationale: The correct answer is B because monitoring the site and progress of the infusion every hour is crucial to prevent complications like infiltration or infection in clients with hypertension. Choice A is incorrect as checking BP every hour is excessive. Choice C is incorrect as daily monitoring may not detect issues promptly. Choice D is incorrect as pulse rate monitoring is not directly related to IV fluid administration in this context. Monitoring the site and progress hourly ensures timely intervention if any issues arise.
Question 3 of 9
The thymus gland role with the immune system is which of the following?
Correct Answer: D
Rationale: The correct answer is D: Maturates T cells. The thymus gland is crucial for the maturation of T cells, a type of white blood cell that plays a central role in the adaptive immune response. T cells mature in the thymus through a process of selection and education, where they learn to distinguish self from non-self antigens. This process is essential for the development of a functional immune system. Choices A, B, and C are incorrect because the thymus gland does not play a role in the maturation of B cells, platelets, or red blood cells, respectively.
Question 4 of 9
Mr. Mariano was on his way home from a party. Apparently, he got drunk and lost his balance and suffered a vehicular accident. Upon arrival at the hospital, the nurse noticed that his only injury is an open fracture of the left humerus. Which assessment finding by the nurse is critical?
Correct Answer: A
Rationale: The correct answer is A: status of client’s tetanus immunization. It is critical because an open fracture poses a risk of infection, and tetanus prophylaxis is necessary to prevent tetanus infection. Tetanus is caused by a bacterium commonly found in soil and can enter the body through open wounds. Assessing the client's tetanus immunization status helps determine the need for a tetanus booster to prevent potential complications. Incorrect choices: B: Current blood alcohol level - While relevant to the situation, the priority in this case is preventing infection from the open fracture. C: Support systems available at home to assist with care - Important for discharge planning but not the immediate priority. D: Last time client voided - Not critical in this scenario compared to preventing infection from the open fracture.
Question 5 of 9
The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?
Correct Answer: C
Rationale: The correct next step after identifying nursing diagnoses is planning. Planning involves setting goals and creating a plan of care to address the patient's needs based on the identified nursing diagnoses. This step helps in determining interventions and outcomes for the patient. Assessment has already been completed, and diagnosis is the step where nursing diagnoses are identified. Implementation comes after planning, where the nurse carries out the planned interventions. Therefore, the logical next step in the nursing process after identifying nursing diagnoses is planning.
Question 6 of 9
Mr. Sison had an above the knee amputation (AKA). He is taught to use crutches while prosthesis is being adjusted. The nurse instruct the client to support her weight primarily on which areas?
Correct Answer: A
Rationale: The correct answer is A: axilla. When using crutches, weight should primarily be supported on the axilla to prevent nerve and blood vessel damage in the armpit area. Supporting weight on the upper arms (B) can lead to nerve compression and muscle strain. Supporting weight on the elbows (C) can cause nerve damage and discomfort. Supporting weight on the hands (D) can lead to hand and wrist pain and may not provide stable support. Therefore, the axilla is the most appropriate area to support weight while using crutches to ensure safety and comfort for the client.
Question 7 of 9
A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Ambulating a patient. Direct care interventions involve hands-on activities directly impacting patient outcomes. Ambulating a patient is a direct care intervention as it involves physically assisting the patient to move, promoting circulation, preventing complications, and improving overall well-being. Inserting a feeding tube (B) and performing resuscitation (C) are also direct care interventions as they involve immediate patient care actions. Documenting wound care (D) is not a direct care intervention as it involves recording information about a care activity rather than physically performing the care itself.
Question 8 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.
Question 9 of 9
In the operating room, personnel should be responsible for ensuring cleanliness, proper temperature, humidity, and lighting. Who carries those responsibilities?
Correct Answer: A
Rationale: The correct answer is A: circulating nurse. The circulating nurse is responsible for maintaining cleanliness, ensuring proper temperature, humidity, and lighting in the operating room. They coordinate activities, manage supplies, and ensure a safe environment for the surgical team. The scrub nurse assists the surgeon with instruments and supplies, not environmental conditions. The surgeon's main focus is on performing the surgery, not environmental management. The anesthesiologist is responsible for administering anesthesia and monitoring the patient's vital signs, not the operating room environment.