ATI RN
Nursing Process Exam Questions Questions
Question 1 of 9
A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity. This is the highest priority as patients with spinal cord injuries are at high risk for pressure ulcers due to immobility. Preventing skin breakdown is crucial to avoid complications. Choices B, C, and D are not as urgent. Choice B may be a concern but preventing skin breakdown takes precedence. Choices C and D are important but not life-threatening like potential skin issues in this patient population.
Question 2 of 9
A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity. This is the highest priority as patients with spinal cord injuries are at high risk for pressure ulcers due to immobility. Preventing skin breakdown is crucial to avoid complications. Choices B, C, and D are not as urgent. Choice B may be a concern but preventing skin breakdown takes precedence. Choices C and D are important but not life-threatening like potential skin issues in this patient population.
Question 3 of 9
Which of the ff precautions must a nurse take while caring for clients with HIV/AIDS to reduce occupational risks?
Correct Answer: A
Rationale: The correct answer is A. Transporting specimens of body fluid in leakproof containers reduces the risk of exposure to HIV/AIDS. This precaution ensures that any potentially infectious material is securely contained. Choice B is incorrect as fusion inhibitors are not prescribed for reducing occupational risks. Choice C is incorrect as it does not directly address reducing occupational risks related to HIV/AIDS. Choice D is incorrect as it is essential for a nurse to clean the client's room, but with proper precautions in place to prevent exposure to bodily fluids.
Question 4 of 9
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
Correct Answer: A
Rationale: Step 1: Recognize cultural differences in communication styles. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness. Step 2: Understand that the patient's behavior may not indicate depression but rather a cultural norm. Step 3: Adjust communication approach by respecting the patient's cultural preferences. Step 4: Building trust and rapport by acknowledging and accommodating cultural differences. Summary: Choice A is correct as it acknowledges and respects cultural differences. Choices B, C, and D are incorrect as they do not consider cultural aspects and may lead to misinterpretation and inappropriate actions.
Question 5 of 9
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking the beta receptors in the heart, which reduces the heart's workload and oxygen demand, making it an effective treatment for angina. By blocking beta stimulation, propranolol helps to decrease heart rate, blood pressure, and myocardial contractility. This ultimately improves oxygen supply to the heart muscle. Explanation for other choices: A: Act as a vasoconstrictor - Propranolol does not act as a vasoconstrictor; it actually can cause vasodilation in some cases. C: Act as a vasodilator - Propranolol is not primarily a vasodilator; its main action is to block beta stimulation in the heart. D: Increase the heart rate - Propranolol actually decreases heart rate by blocking beta receptors in the heart.
Question 6 of 9
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
Correct Answer: A
Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.
Question 7 of 9
What orders would likely be included fro a client diagnosed with multiple myeloma?
Correct Answer: C
Rationale: The correct answer is C, Corticosteroid therapy. In multiple myeloma, corticosteroids are commonly used to help reduce inflammation, suppress the immune system, and slow the growth of cancer cells. This treatment can help manage symptoms and improve quality of life for the client. A: Bed rest is not typically prescribed for multiple myeloma unless there are specific complications requiring immobilization. B: Fluid restriction is not a common treatment for multiple myeloma unless there is a specific need to manage fluid balance. D: Calcium replacement therapy may be necessary in some cases of multiple myeloma due to bone involvement, but it is not a primary treatment option compared to corticosteroid therapy in managing the disease.
Question 8 of 9
The normal range of hemoglobin in the blood of an adult:
Correct Answer: C
Rationale: The normal range of hemoglobin in adult blood is typically between 12-18 g/dL. This range is the most common and widely accepted range based on clinical guidelines and research studies. Hemoglobin levels outside this range may indicate anemia or other health conditions. Choice A (7-11 mg) is too low for normal hemoglobin levels in adults and indicates severe anemia. Choice B (14-20 mg) is slightly higher and could be normal for some individuals, but generally, 12-18 g/dL is the standard range. Choice D (20-26 mg) is too high and may indicate dehydration or other medical conditions.
Question 9 of 9
In the presence of coma or unconsciousness, the major therapeutic measure includes:
Correct Answer: A
Rationale: The correct answer is A: Maintenance of a clear airway. In cases of coma or unconsciousness, ensuring a clear airway is crucial to prevent respiratory complications and maintain oxygenation. This involves positioning the patient correctly, suctioning if necessary, and monitoring breathing. Choice B, good nursing care, is too broad and does not address the immediate priority of airway management. Choice C, retention of a catheter, is irrelevant to managing a coma or unconsciousness. Therefore, the correct therapeutic measure in this scenario is to focus on maintaining a clear airway to support respiratory function.