ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
A nurse teaches a client newly diagnosed with diabetes how to administer insulin. What type of nursing intervention is this?
Correct Answer: A
Rationale: Correct Answer: A (Independent intervention) Rationale: 1. Independent interventions are actions that nurses can initiate without a doctor's order. 2. Teaching a client how to administer insulin falls under the scope of nursing practice. 3. Nurses have the knowledge and authority to educate clients on self-care management. 4. This intervention does not require collaboration with other healthcare providers. Summary: B: Dependent interventions require a doctor's order. C: Interdependent interventions involve collaboration with other healthcare providers. D: Collaborative interventions involve working with other healthcare professionals.
Question 2 of 5
The nurse notes frequent muscle twitching when collecting admission data on a patient admitted for increasing muscle weakness. Which of the ff. terms should the nurse use to document this?
Correct Answer: A
Rationale: The correct answer is A: Fasciculations. Fasciculations are involuntary muscle twitches commonly seen with neurological conditions like motor neuron disease. In this case, the patient's muscle weakness and frequent muscle twitching indicate possible nerve damage. Chorea (B) is characterized by involuntary, jerky movements, not twitching. Atrophy (C) refers to muscle wasting, not twitching. Neuropathy (D) is a general term for nerve damage and does not specifically describe the muscle twitching seen in this patient.
Question 3 of 5
While managing a client after a medical or surgical procedure for bladder stones, for what rise in the temperature should the nurse notify the physician?
Correct Answer: C
Rationale: The correct answer is C: When the temperature rises above 102F. A temperature rise above 102F is concerning as it may indicate infection or other complications post-procedure. This higher threshold helps in early detection and timely intervention. Choices A and B set lower thresholds, potentially delaying necessary medical attention. Choice D is below the typical threshold for fever and would not typically warrant physician notification in this context.
Question 4 of 5
Which of the ff symptoms is associated with AIDS related distal sensory polyneuropathy (DSP)?
Correct Answer: B
Rationale: The correct answer is B: Abnormal sensations such as burning and numbness. In AIDS-related DSP, damage to nerves causes abnormal sensations like burning and numbness. This is due to the progressive nerve damage affecting sensory functions. Staggering gait and muscle incoordination (A) are more common in conditions affecting motor nerves. Delusional thinking (C) is not a symptom of DSP. Incontinence (D) is not typically associated with DSP but may happen in more advanced stages due to loss of sensation.
Question 5 of 5
Which is the most reliable method for monitoring fluid balance?
Correct Answer: A
Rationale: The correct answer is A: Daily intake and output. Monitoring fluid balance involves tracking the amount of fluids taken in and expelled from the body. Intake includes oral, IV, and tube feedings, while output includes urine, vomitus, diarrhea, and any other fluid losses. Daily intake and output provide a comprehensive view of a patient's fluid status, helping identify trends and potential issues. Vital signs (B) provide general information but not specific to fluid balance. Daily weight (C) can fluctuate due to various factors, not just fluid status. Skin turgor (D) is a late sign of dehydration and not as reliable as intake and output monitoring.
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