Questions 9

ATI RN

ATI RN Test Bank

ADPIE Nursing Process Questions Questions

Question 1 of 5

A patient admitted with gastrointestinal tract bleeding has a hemoglobin level of 6 g/dL. She asks the nurse why she feels SOB. Which response is best?

Correct Answer: B

Rationale: The correct answer is B because hemoglobin carries oxygen to the tissues, and with a low hemoglobin level of 6 g/dL, there is insufficient oxygen-carrying capacity to meet the body's needs, leading to shortness of breath (SOB). Choice A is incorrect as anemia affects oxygen transport, not absorption. Choice C is incorrect as anemia affects oxygen delivery, not nutrient delivery. Choice D is incorrect as the primary reason for SOB in this scenario is the lack of oxygen-carrying capacity due to low hemoglobin levels, not lung damage from blood loss.

Question 2 of 5

Which of the following client outcomes best describes the parameters for achieving the outcome?

Correct Answer: B

Rationale: The correct answer is B because it provides specific, measurable, achievable, relevant, and time-bound (SMART) parameters for achieving the outcome. It outlines the calorie intake, meal frequency, and start date, which allows for clear monitoring and evaluation of progress. Choice A is too vague and lacks specificity. Choice C focuses on wound care, not dietary goals. Choice D lacks specificity and a timeframe, making it difficult to measure success. In conclusion, choice B is the best option as it aligns with effective goal-setting principles.

Question 3 of 5

Nursing care for a patient who is experiencing a convulsive seizure includes all of the following except:

Correct Answer: B

Rationale: The correct answer is B because inserting a mouth gag during a convulsive seizure can obstruct the airway and pose a choking hazard. Step-by-step rationale: A: Loosening clothing helps improve ventilation. C: Positioning on the side with head flexed forward prevents aspiration. D: Providing privacy is important for patient dignity and confidentiality. B is incorrect as it can be harmful.

Question 4 of 5

An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?

Correct Answer: C

Rationale: The correct answer is C: Alteration in tissue perfusion related to bleeding and diminished blood flow. Disseminated intravascular coagulation (DIC) is a condition where blood clots form throughout the body, leading to both bleeding and clotting. This can result in decreased blood flow to tissues, causing tissue perfusion issues. Explanation: 1. Option A: Risk for increased cardiac output related to fluid volume excess is incorrect because DIC can lead to bleeding, causing a decrease in blood volume and potentially decreasing cardiac output. 2. Option B: Disturbed sensory perception related to bleeding into tissues is incorrect as DIC primarily affects blood clotting and bleeding, not sensory perception. 3. Option D: Risk for aspiration related to constriction of the respiratory musculature is incorrect as DIC does not directly cause constriction of respiratory muscles, but rather impacts the clotting and bleeding processes in the body. In summary, the correct answer is C because DIC can lead to altered tissue perfusion

Question 5 of 5

The nurse is taking vital signs of a pregnant woman during her first prenatal visit. The patient asks the nurse if she has to have an HIV test. Which of the following is the nurse’s best response?

Correct Answer: A

Rationale: Rationale for Correct Answer (A): The nurse's best response is to inform the pregnant woman that all pregnant women must have an HIV test. This is because HIV testing is a standard part of prenatal care to prevent mother-to-child transmission. It is crucial to detect HIV early to provide appropriate treatment and prevent transmission to the baby. Summary of Incorrect Choices: B: This response could lead to misinformation and potentially harm the patient and her baby. HIV testing is recommended for all pregnant women regardless of risk factors. C: While governmental guidelines may vary, it is essential for all pregnant women to undergo HIV testing to ensure the health of both the mother and the baby. D: While it is important to provide counseling and involve the patient in decision-making, in the case of HIV testing during pregnancy, it is a standard procedure that should be offered to all pregnant women to safeguard their health and that of their baby.

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