ATI RN
Nursing Process Practice Questions Questions
Question 1 of 9
A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future?
Correct Answer: A
Rationale: The correct answer is A: The nurse should practice interviewing strategies. This is the best remedy because improving the nurse's ability to gather comprehensive information during client history will ensure sufficient data for planning interventions. By practicing interviewing strategies, the nurse can learn to ask relevant questions, actively listen, and probe for additional details. Summary: B: Modifying the data collection tool may not address the issue of insufficient information if the problem lies with how the nurse conducts the interview. C: Determining the specific purpose of data collection is important but may not solve the immediate issue of lacking information for intervention planning. D: Updating the database is irrelevant to the problem of inadequate data collection during client history.
Question 2 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 3 of 9
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Correct Answer: D
Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.
Question 4 of 9
What does a nurse assess postoperatively in a client with a nasal fracture?
Correct Answer: C
Rationale: The correct answer is C: Airway obstruction. Postoperatively, a nurse must assess for airway patency in a client with a nasal fracture to ensure proper breathing. Any swelling or bleeding in the nasal area can lead to airway obstruction, which is a critical concern that needs immediate intervention. Choices A, B, and D are incorrect because an allergic reaction, extreme sense of smell, and stridor are not typically associated with postoperative assessment of a nasal fracture. It is crucial to prioritize airway assessment to prevent any complications related to breathing difficulties in this situation.
Question 5 of 9
Which finding will alert the nurse that the goal has been met?
Correct Answer: A
Rationale: The correct answer is A because it meets the goal of maintaining a heart rate of 78 beats/min. This specific date ensures the consistency of the heart rate within the desired range. Choices B, C, and D do not align with the goal as they either have a different heart rate or occur on a different date. Therefore, A is the only option that accurately reflects the goal being met on the specified date.
Question 6 of 9
Which of the following actions should the nurse take to maintain patient safety when ambulating a patient for the first time postoperatively?
Correct Answer: B
Rationale: The correct answer is B: Use two people to assist the patient. This is the safest option as it provides optimal support and stability for the patient during their first postoperative ambulation. Two people can help prevent falls, ensure proper body mechanics, and offer immediate assistance if needed. Using one person (choice A) may not provide enough support. Encouraging the patient to "dangle" (choice C) may increase the risk of orthostatic hypotension. Giving a narcotic before ambulation (choice D) can impair the patient's balance and coordination, increasing the risk of falls.
Question 7 of 9
A client is diagnosed with metastatic adenocarcinoma of the stomach. The physician prescribes mitomycin (Mutamycin) with other chemotherapeutic agents for palliative treatment. How mitomycin does exert its cytotoxic effects?
Correct Answer: A
Rationale: The correct answer is A: It inhibits deoxyribonucleic acid (DNA) synthesis. Mitomycin works by cross-linking DNA, leading to inhibition of DNA synthesis and ultimately causing cell death. This mechanism of action makes it effective against rapidly dividing cancer cells. B: It’s cell cycle-phase specific - This is incorrect because mitomycin is not specific to a particular phase of the cell cycle. C: It inhibits ribonucleic acid (RNA) synthesis - This is incorrect as mitomycin primarily targets DNA synthesis, not RNA synthesis. D: It inhibits protein synthesis - This is incorrect as mitomycin's main mechanism of action is through DNA cross-linking, not protein synthesis inhibition.
Question 8 of 9
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
Correct Answer: C
Rationale: The correct answer is C: Stop the transfusion. Lumbar pain during blood administration could indicate a transfusion reaction, such as a hemolytic reaction or fluid overload. Stopping the transfusion is crucial to prevent further harm to the client. Obtaining vital signs (A) is important but not the priority when a transfusion reaction is suspected. Assessing the pain further (B) may delay necessary intervention. Increasing the flow of normal saline (D) is not indicated and may worsen fluid overload. In this situation, stopping the transfusion is the most appropriate action to ensure client safety.
Question 9 of 9
A patient asks the nurse what her diagnosis of heart failure means. Which of the ff. is the nurse’s best response?
Correct Answer: D
Rationale: The correct answer is D: “Your heart is not an efficient pump.” This response is the best choice as it accurately describes heart failure, which is a condition where the heart is unable to pump blood effectively. This leads to symptoms such as fatigue, shortness of breath, and fluid retention. Explanation: 1. Choice A is incorrect because heart failure does not mean the heart stops; it means the heart is not functioning properly. 2. Choice B is incorrect because heart failure does not necessarily mean there is dead muscle tissue in the heart. 3. Choice C is incorrect because heart failure is not about pumping too much blood; it is about the heart's inability to pump blood efficiently, leading to circulation problems and other symptoms.