Questions 9

ATI RN

ATI RN Test Bank

Nursing Process Practice Questions Questions

Question 1 of 5

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 gathering data related to the patient's current health issue or concern. This step is crucial as it helps identify the primary problem and sets the direction for further data collection and analysis. By focusing on the patient's presenting situation, the nurse can prioritize information gathering and make informed decisions about the next steps in care. Incorrect choices: A: Completing questions in chronological order may not be relevant to the patient's current issue and could lead to missing important details. C: Making accurate interpretations of the data comes after data collection, so it is not the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to gather specific information.

Question 2 of 5

Severe and extensive hemolysis causes which of the ff?

Correct Answer: B

Rationale: Severe and extensive hemolysis leads to the release of large amounts of hemoglobin into the bloodstream, causing hemoglobinemia. This can result in hemoglobinuria, leading to acute renal failure and ultimately shock. Shock is the correct answer as it is a severe consequence of extensive hemolysis. Leg ulcers (A) may occur in conditions like peripheral arterial disease. Priapism (C) is unrelated to hemolysis. Compromised growth (D) is not a common consequence of hemolysis.

Question 3 of 5

A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:

Correct Answer: C

Rationale: The correct answer is C: fluid volume deficit. In diabetes insipidus, there is an excessive amount of dilute urine excreted, leading to dehydration and fluid volume deficit. The posterior pituitary tumor causes a deficiency in antidiuretic hormone (ADH), which regulates water reabsorption in the kidneys. As a result, the client experiences polyuria and polydipsia, leading to fluid volume deficit. Choices A, B, and D are incorrect because diabetes insipidus does not cause fluid volume excess, incontinence, or diarrhea. The key is to recognize the pathophysiology of diabetes insipidus and its impact on fluid balance.

Question 4 of 5

Choose the condition th₃a⁻t exhibits blood values with a low pH and a low plasma bicarbonate concentration:

Correct Answer: B

Rationale: Step-by-step rationale: 1. Metabolic acidosis is characterized by low pH and low plasma bicarbonate. 2. In this condition, there is an excess of acids or a loss of bicarbonate. 3. The kidneys are unable to adequately excrete acids or retain bicarbonate. 4. This leads to a decrease in bicarbonate levels and a decrease in pH. 5. Respiratory acidosis (A) is characterized by low pH and high CO2 levels. 6. Respiratory alkalosis (C) is characterized by high pH and low CO2 levels. 7. Metabolic alkalosis (D) is characterized by high pH and high bicarbonate levels. Summary: - Choice A is incorrect as it describes a condition with high CO2 levels. - Choice C is incorrect as it describes a condition with high pH. - Choice D is incorrect as it describes a condition with high bicarbonate levels. - Choice B is correct as it accurately describes the characteristics of a condition with low pH

Question 5 of 5

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.

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