ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?
Correct Answer: C
Rationale: The correct nursing diagnosis is C: Deficient fluid volume. The patient's symptoms indicate dehydration, as evidenced by tachycardia, increased thirst, decreased urine output, and increased body temperature. This points to a lack of fluid in the body. Option A, adult failure to thrive, does not address the immediate issue of fluid volume. Option B, hypothermia, is incorrect as the patient has an increased body temperature. Option D, nausea, is not a primary issue compared to the symptoms indicating dehydration. Therefore, the correct nursing diagnosis is C: Deficient fluid volume.
Question 2 of 5
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself?
Correct Answer: D
Rationale: The correct answer is D: Sitting at a 45-degree angle to the bed. This position allows the nurse to have a clear view of the client and maintain good communication. Sitting at a 45-degree angle enables the nurse to observe the client's facial expressions, body language, and interact effectively. Standing at the end of the bed (A) limits the nurse's view and communication. Standing at the side of the bed (B) may obstruct the nurse-client interaction. Sitting at least six feet away (C) creates unnecessary distance and hinders effective communication.
Question 3 of 5
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
Correct Answer: B
Rationale: The correct answer is B: Maintaining a patent airway. This is the highest priority because the client with esophageal cancer is at risk for airway obstruction due to difficulty swallowing. Maintaining a patent airway ensures adequate oxygenation and ventilation, which are vital for the client's survival. Without a clear airway, the client may experience respiratory distress or failure. Body image, preventing injury, and ensuring adequate nutrition are important aspects of care but do not take precedence over maintaining a patent airway in this situation.
Question 4 of 5
Which of the following diets would the nurse include in the plan of care for a person with AIDS?
Correct Answer: A
Rationale: The correct answer is A: A high-protein, high-calorie diet divided into six small meals. For a person with AIDS, this diet is beneficial to maintain muscle mass, support immune function, and provide energy. High-protein helps in tissue repair, while high-calorie intake helps combat weight loss common in AIDS. Dividing into small frequent meals aids in digestion and absorption. Choice B is incorrect because a low-fat diet may not provide enough calories for the increased energy needs of a person with AIDS. Choice C is incorrect because a high-carbohydrate, fat-restricted diet may not provide sufficient protein for muscle maintenance. Choice D is incorrect because a high-fat diet may lead to weight gain and can be harder to digest for someone with compromised immunity.
Question 5 of 5
Hemodynamic monitoring by means of a multilumen pulmonary artery catheter can provide detailed information about:
Correct Answer: D
Rationale: The correct answer is D because a multilumen pulmonary artery catheter can provide detailed information about preload, afterload, and cardiac output. Preload refers to the volume of blood in the ventricles at the end of diastole, afterload is the resistance the heart has to overcome to eject blood, and cardiac output is the amount of blood pumped by the heart per minute. This catheter allows for direct measurement of these parameters by monitoring pressures in the pulmonary artery. Choices A, B, and C are incorrect individually as they do not encompass the full range of information that can be obtained with a multilumen pulmonary artery catheter.
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