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. This is because in the problem-oriented approach, the nurse must first gather data related to the patient's current issue or concern. This initial focus helps in identifying the primary problem, setting priorities, and developing a care plan. Now, let's analyze the other choices: A: Completing questions in chronological order may not be necessary or relevant to addressing the patient's immediate issue. 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 should come after focusing on the patient's presenting situation to gather specific and relevant data.
Question 2 of 9
The knows that a positive diagnosis for HIV infection is made based on; a.A history of high-risk sexual behaviors
Correct Answer: A
Rationale: The correct answer is A because a positive diagnosis for HIV infection is confirmed through laboratory testing, specifically the ELISA and Western blot tests. These tests detect the presence of HIV antibodies in the blood, providing definitive evidence of the infection. Choice B is incorrect as weight loss and fever are symptoms but not diagnostic criteria. Choice C is incorrect as opportunistic infections are a consequence of HIV, not the diagnostic criteria. Choice D is incomplete and irrelevant. In summary, the key to diagnosing HIV is through positive laboratory tests, not just based on symptoms or associated infections.
Question 3 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 4 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 5 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 6 of 9
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?
Correct Answer: A
Rationale: Correct Answer: A - Cerebral edema Rationale: 1. SIADH leads to water retention and dilutional hyponatremia. 2. Diuretic therapy aims to increase urine output and correct fluid imbalance. 3. If the client does not comply, excessive water retention can lead to cerebral edema. 4. Cerebral edema is a serious complication that can cause neurological deficits. Summary: - B: Severe hyperkalemia is unlikely as diuretics would help excrete excess potassium. - C: Hypovolemic shock is not expected as fluid restriction may prevent rapid volume loss. - D: Tetany is not a direct consequence of non-compliance with treatment for SIADH.
Question 7 of 9
Which of the ff interventions is implemented for a client with empyema?
Correct Answer: D
Rationale: The correct answer is D: Emphasize the completion of the entire course of drug therapy. Empyema is a serious condition that requires antibiotic treatment. Emphasizing the completion of the entire course of drug therapy is crucial to ensure that the infection is completely eradicated and to prevent the development of drug-resistant strains. Teaching breathing exercises (choice A) may help improve lung function but is not the primary intervention for empyema. Offering assurance that empyema takes less time to resolve (choice B) is incorrect as it can mislead the client about the seriousness of the condition. Recommending a balanced but light diet (choice C) may be beneficial for overall health but is not directly related to treating empyema.
Question 8 of 9
Which of the ff. nursing actions is most appropriate when doing perineal care on an uncircumcised male patient?
Correct Answer: C
Rationale: The correct answer is C, which is to replace the foreskin over the head of the penis after washing. This is important to prevent any irritation or injury to the sensitive foreskin and glans. Leaving the foreskin retracted (A) can lead to discomfort and potential injury. Not retracting the foreskin (B) may not allow for proper cleaning. Using alcohol and a cotton swab (D) can be too harsh and irritating to the delicate tissues. Therefore, option C is the most appropriate and gentle approach to maintain proper hygiene and prevent any complications.
Question 9 of 9
.A client complains of urinary discomfort and a burning sensation while urinating. A urethral smear shows evidence of urethritis, and the client is prescribed antibiotics and instructed to drink 2-3 L of water daily. For which of the ff reasons is the client advised to drink the specified amount of water?
Correct Answer: B
Rationale: Step 1: Antibiotics are prescribed to treat urethritis, indicating a bacterial infection in the urinary tract. Step 2: Increasing water intake (2-3 L daily) promotes renal blood flow, dilutes urine, and helps flush out bacteria from the urinary tract, aiding in the elimination of infection. Step 3: Adequate hydration helps prevent the formation of concentrated urine, reducing the risk of recurrent urinary tract infections. Step 4: Therefore, choice B is correct as it directly addresses the underlying cause of the client's symptoms. Summary: Choices A, C, and D are incorrect as they do not directly target the bacterial infection causing the urinary discomfort. Drinking water will not specifically help with incontinence, eliminate odors, or provide pain relief.