ATI RN
Nursing Process Test Questions Questions
Question 1 of 5
A patient complains of tingling in his fingers. He has positive Trousseau’s and Chvostek’s signs. He says that he feels depressed. Choose the most likely serum calcium (Ca ) value for this patient:
Correct Answer: A
Rationale: The correct answer is A: 11mg/dl. This patient is likely experiencing hypocalcemia, indicated by positive Trousseau's and Chvostek's signs. These signs suggest neuromuscular irritability due to low calcium levels. A serum calcium level of 11mg/dl is higher than normal, indicating possible hyperparathyroidism causing high calcium levels. Choices B, C, and D are lower than normal, which would exacerbate symptoms rather than alleviate them.
Question 2 of 5
A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
Correct Answer: D
Rationale: The correct answer is D, Leucovorin. Leucovorin is administered with methotrexate to protect normal cells from methotrexate toxicity by acting as a "rescue" agent. Methotrexate inhibits dihydrofolate reductase, leading to decreased levels of tetrahydrofolate needed for DNA synthesis. Leucovorin bypasses this step by directly providing the reduced form of folic acid, thus preventing toxicity in normal cells. Probenecid (choice A) is not used to protect normal cells during methotrexate therapy. Cytarabine (choice B) and Thioguanine (choice C) are not rescue agents for methotrexate toxicity.
Question 3 of 5
When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
Correct Answer: B
Rationale: The correct answer is B: Hives or rashes. In autoimmune disorders, the immune system mistakenly attacks the body's own tissues, leading to various symptoms. Hives or rashes are common manifestations of autoimmune disorders due to the immune response affecting the skin. Other choices are incorrect because hypotension is not typically associated with autoimmune disorders, localized inflammation may be present but is not specific to autoimmune disorders, and cramping and vomiting are not primary signs of autoimmune disorders.
Question 4 of 5
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
Correct Answer: C
Rationale: The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage. A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin. B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers. D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.
Question 5 of 5
Mr. Umali, 52-year-old male is being evaluated for acute ulcerative colitis. im preparing Mr. Umali for a barium enema, the nurse can expect that he will be:
Correct Answer: A
Rationale: The correct answer is A because cathartics can exacerbate ulcerative colitis symptoms by increasing bowel motility and causing further inflammation. Giving an oil retention enema (choice B) is not necessary for a barium enema. Ingesting radiopaque tablets (choice C) is not typically part of the preparation for a barium enema. Positioning the patient in a high Fowler's position (choice D) is not a specific requirement following the procedure. Overall, avoiding cathartics is crucial in patients with acute ulcerative colitis to prevent worsening of symptoms during the barium enema.
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