Questions 9

ATI RN

ATI RN Test Bank

Nursing Process Test Questions Questions

Question 1 of 5

A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?

Correct Answer: C

Rationale: The correct answer is C: Time-lapsed assessment. This type of assessment involves comparing baseline data with new data collected at a later time to evaluate changes in the client's condition. In this scenario, the nurse is reassessing the client a month later to determine if there have been any changes that require adjustments to the care plan. A: Comprehensive assessment is an in-depth assessment done initially to gather detailed information about the client's overall health status. B: Focused assessment is done to gather specific information related to a particular problem or issue. D: Emergency assessment is performed in urgent situations to quickly identify and address life-threatening conditions.

Question 2 of 5

A patient is being taught the action of digoxin, which is an inotropic agent. The nurse defines an inotropic agent as a medication that has which of the following actions?

Correct Answer: D

Rationale: The correct answer is D: Strengthens heart contraction. Digoxin is an inotropic agent that works by increasing the force of the heart's contractions. This leads to improved cardiac output and helps manage conditions like heart failure. Choices A, B, and C are incorrect because digoxin does not decrease heart rate, increase conduction time, or increase heart rate. It specifically targets the strength of the heart's contractions, making option D the most appropriate choice. This action of digoxin is crucial in improving the efficiency of the heart's pumping function.

Question 3 of 5

Which of the ff nursing interventions ensure that a client with Hodgkin’s disease remains free of infection? Choose all that apply

Correct Answer: C

Rationale: Rationale: C: Practice conscientious hand washing is correct as it helps prevent the spread of infection. Proper hand hygiene is essential in reducing the risk of infection transmission to the client with Hodgkin's disease. A: Apply ice to the skin for brief periods is incorrect as it does not directly relate to preventing infection in the client. B: Provide cool sponge baths is incorrect as it mainly addresses comfort and hygiene but does not specifically target infection prevention. D: Use cotton gloves Restrict visitors or personnel with infections from contact with the client is incorrect because while using gloves can help prevent the spread of infection, restricting visitors with infections is not under the direct control of the nurse. Summary: Practicing conscientious hand washing is crucial in preventing infection in a client with Hodgkin's disease, while the other choices do not directly address infection control in this context.

Question 4 of 5

Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?

Correct Answer: C

Rationale: The correct answer is C: increased serum ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia, leading to its accumulation in the bloodstream, causing altered thought processes. This results in confusion and asterixis. Massive ascites formation (choice A) is related to fluid accumulation in the peritoneal cavity, not directly linked to altered thought processes. Fluid volume excess (choice B) is a general fluid imbalance issue, not specific to hepatic encephalopathy. Altered clotting mechanism (choice D) is more associated with hepatic dysfunction leading to impaired clotting factors, not directly linked to altered thought processes.

Question 5 of 5

The physician prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a client with type 2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and exercise. Which medication instruction should the nurse provide?

Correct Answer: A

Rationale: The correct answer is A: “Be sure to take glipizide 30 minutes before meals.” This instruction is correct because glipizide is an oral antidiabetic agent that works best when taken before meals to help control blood glucose levels. Taking it before meals allows the medication to coincide with the body's natural insulin response to food intake, thereby improving its effectiveness. Choice B is incorrect because glipizide does not typically cause low serum sodium levels, so there is no need for monthly sodium level checks. Choice C is incorrect because it is essential for the client to continue monitoring their blood glucose levels even after starting glipizide to ensure the medication is working effectively. Choice D is incorrect because taking glipizide after a meal will not optimize its effectiveness in controlling blood glucose levels.

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