ATI RN
Fundamentals of Nursing Nursing Process Questions Questions
Question 1 of 9
A nursing intervention for anemia is:
Correct Answer: B
Rationale: The correct answer is B, a high protein, vitamin, and iron diet, as it directly addresses the nutritional deficiencies associated with anemia. Proteins aid in the production of red blood cells, while iron and vitamins are essential for hemoglobin synthesis. Medical therapy (A) typically involves medications or blood transfusions, not dietary changes. Fluid therapy (C) may be used for certain types of anemia, but it is not a primary intervention. Chemotherapy (D) is not indicated for the treatment of anemia, as it is used for cancer treatment. Therefore, choice B is the most appropriate intervention for anemia.
Question 2 of 9
Which of the ff nursing actions is helpful for older clients who are experiencing lens changes associated with aging?
Correct Answer: D
Rationale: The correct answer is D, suggesting the use of glasses or contact lenses. This is because as older clients experience lens changes associated with aging, they may develop presbyopia or other vision issues that can be corrected with corrective lenses. Glasses or contact lenses can help improve their vision and quality of life. A, offering teaching aids with large-sized letters, may be helpful for clients with visual impairments but may not directly address the specific lens changes associated with aging. B, suggesting reduced visual activity, is not beneficial as it may further limit the client's engagement in daily activities and social interactions. C, suggesting the use of eye drops for comfort, may provide temporary relief for dry eyes but does not address the underlying lens changes affecting vision.
Question 3 of 9
The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;
Correct Answer: B
Rationale: The correct answer is B - Avoid traumatic injuries and exposure to any infection. For a client with pancytopenia caused by chemotherapy, their immune system is compromised, making them more susceptible to infections and bleeding. By avoiding traumatic injuries and exposure to infections, the client can reduce the risk of complications. Option A is incorrect because aggressive mouth care may further damage the already compromised oral mucosa. Option C is incorrect because excessive fluid intake may not be necessary and could worsen electrolyte imbalances. Option D is incorrect because muscle cramps and tingling sensations are not directly related to the main concern of infection and bleeding in pancytopenia.
Question 4 of 9
Which method of data collection will the nurse use to establish a patient’s database?
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather objective data directly from the patient's body, such as vital signs, appearance, and physical findings. It is essential for establishing a patient's baseline health status and identifying any abnormalities or changes. Reviewing literature (A) is important but not a method of data collection. Checking orders (B) is part of the assessment process but does not involve direct data collection. Ordering medications (D) is a clinical intervention and not a data collection method.
Question 5 of 9
Clients who will go through operations and who have undergone surgery need the proper observation, treatment and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria checks on Mr. Alberto who had abdominal surgery, and finds that the edges of the incision have separated. Also, a small portion of the bowel is sticking out through the incision. Nurse Maria would:
Correct Answer: A
Rationale: Correct Answer: A: Cover wound with moist sterile dressing Rationale: 1. Covering the wound with a moist sterile dressing helps maintain a clean and moist environment, promoting wound healing. 2. Moist dressing prevents the wound from drying out and minimizes the risk of infection. 3. The moist environment supports healing by promoting cell growth and preventing tissue damage. 4. It protects the exposed bowel from further injury and contamination. Summary: B: Finding out how this happened is important but not an immediate priority for patient care. C: Placing sterile dry gauze can lead to the wound drying out and hinder healing. D: Pouring sterile water into the wound is not recommended as it can introduce contaminants and is not considered standard care for this situation.
Question 6 of 9
Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:
Correct Answer: D
Rationale: The correct answer is D: Aphasia. Mr. Dela Isla's inability to comprehend what the nurse was saying indicates a language impairment, which is characteristic of aphasia. Aphasia is a condition that affects a person's ability to understand or produce language due to damage to the brain's language centers. Insomnia (A) is a sleep disorder, Agnosia (B) is a perception disorder, and Apraxia (C) is a motor planning disorder, none of which align with Mr. Dela Isla's symptoms.
Question 7 of 9
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
Correct Answer: B
Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This takes highest priority as compromised airway can lead to respiratory distress and potential respiratory failure. Maintaining clear airways is essential for oxygenation and ventilation. Choices A, C, and D are important but do not pose immediate life-threatening risks compared to compromised airway. Disturbed body image, anxiety, and imbalanced nutrition can be addressed once the airway clearance is stabilized.
Question 8 of 9
Which of the ff information should the nurse provide to clients who are prescribed rifampin?
Correct Answer: B
Rationale: The correct answer is B because rifampin can cause discoloration of bodily fluids, including tears. If clients wear contact lenses, they need to be informed that the lenses may become colored due to this medication. This is important for the client's awareness and to prevent any potential harm to their eyes. A: Taking medication with meals is not necessary for rifampin administration. C: Avoiding wearing glasses is not relevant to rifampin treatment. D: Avoiding tuna, aged cheese, and red wine is not specifically related to rifampin use.
Question 9 of 9
During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
Correct Answer: B
Rationale: Step 1: Providing a solution of hydrogen peroxide and water as a mouth rinse helps in reducing the pain of stomatitis by promoting oral hygiene and preventing infections. Step 2: Hydrogen peroxide has antimicrobial properties that can help in reducing bacteria in the mouth, which can worsen stomatitis. Step 3: Rinsing with this solution can also help in cleansing the oral mucosa and reducing inflammation, thereby decreasing pain. Step 4: This intervention directly addresses the nursing diagnosis of impaired oral mucous membrane and is focused on symptom management. Summary: A: Recommending the client to discontinue chemotherapy is not a feasible option as it is essential for treating cancer. C: Monitoring platelet and leukocyte counts is important but does not directly address the pain of stomatitis. D: Checking for signs and symptoms is necessary but does not provide direct relief for the pain of stomatitis.