ATI RN
Nursing Process Questions Questions
Question 1 of 9
A patient has orders to receive 1 L (1000 mL) of 5% dextrose and lactated Ringer’s solution to be infused over 8 hours. How many millilitres will be infused per hour?
Correct Answer: C
Rationale: The correct answer is C: 125 mL/h. To calculate the infusion rate per hour, we divide the total volume (1000 mL) by the total time in hours (8 hours). 1000 mL / 8 hours = 125 mL/h. This ensures a consistent and accurate infusion rate throughout the 8-hour period. Choice A (80 mL/h) is incorrect because it underestimates the infusion rate. Choice B (100 mL/h) is incorrect because it does not divide the total volume by the total time correctly. Choice D (150 mL/h) is incorrect because it overestimates the infusion rate.
Question 2 of 9
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, leading to impaired gas exchange. The nurse correctly identified the underlying respiratory issue. A: Ineffective breathing pattern related to pneumonia is incorrect as it focuses on the pattern of breathing rather than the physiological problem causing the breathing difficulty. B: Risk for infection related to chest x-ray procedure is incorrect as the patient already has a diagnosis of pneumonia, so the focus should be on managing the existing condition. C: Risk for deficient fluid volume related to dehydration is incorrect as there is no indication of dehydration in the question stem. In summary, the nurse's diagnosis of Impaired gas exchange related to alveolar-capillary membrane changes is the most appropriate as it addresses the respiratory issue caused by pneumonia and lower lobe infiltrates.
Question 3 of 9
A 25-year old with hepatitis may be anicteric and symptomless. In the early part of the hepatic inflammatory disorder, the most likely symptom/sign is:
Correct Answer: D
Rationale: The correct answer is D: anorexia. In the early stage of hepatic inflammatory disorder, anorexia is the most likely symptom/sign. This is because hepatic inflammation can lead to a decrease in appetite, resulting in anorexia. Dark urine (A) is commonly associated with liver dysfunction but typically occurs later in the disease process. Occult blood in stools (B) is more indicative of gastrointestinal bleeding rather than early hepatic inflammation. Ascites (C) is the accumulation of fluid in the abdominal cavity and is a later manifestation of liver disease. Therefore, anorexia is the most likely symptom in the early stages of hepatic inflammatory disorder.
Question 4 of 9
Following the American Cancer Society guidelines, the nurse should recommend that the women:
Correct Answer: C
Rationale: The correct answer is C because the American Cancer Society recommends women to have a mammogram annually starting at age 45, then have the option to transition to biennial screening at age 55. This recommendation is based on evidence that regular mammograms can help detect breast cancer early, increasing chances of successful treatment. Choice A is incorrect because self-examinations are no longer recommended as a routine screening method. Choice B is incorrect as clinical breast exams are not as effective as mammograms for detecting breast cancer. Choice D is incorrect as normal receptor assays are not part of routine breast cancer screening guidelines.
Question 5 of 9
A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse during the morning assessment. Early in the afternoon, the patient’s daughter runs out of the room and says, “My mother can’t talk. Somebody help!” Which response by the nurse is best?
Correct Answer: B
Rationale: The correct answer is B. The nurse should do a quick assessment to confirm the change in the patient's status, then notify the RN or physician. This is the best response because the nurse needs to immediately assess the patient's condition to ensure prompt intervention if needed. By confirming the change in the patient's status, the nurse can provide the necessary information to the healthcare team for appropriate evaluation and management. The other choices are incorrect because: A does not address the urgency of the situation, C involves unnecessary delay by waiting for the speech therapist, and D is not appropriate as the nurse should be the one assessing and notifying the healthcare team.
Question 6 of 9
A client is undergoing test for multiple myeloma. Diagnostic study findings in multiple Myeloma includes:
Correct Answer: B
Rationale: The correct answer is B: Bence jones protein in the urine. In multiple myeloma, abnormal plasma cells produce excess monoclonal immunoglobulins, including Bence Jones proteins, which can be detected in the urine. This is a hallmark finding in multiple myeloma diagnosis. A: Incorrect. Serum creatinine levels are typically not affected in multiple myeloma. C: Incorrect. Hypercalcemia, not hypocalcemia, is commonly seen in multiple myeloma due to bone destruction. D: Incorrect. Multiple myeloma often presents with high serum protein levels, not low levels.
Question 7 of 9
Which of the following explanations by the nurse will help a patient understand what to expect during a bronchoscopy?
Correct Answer: A
Rationale: The correct answer is A because it accurately describes the procedure of bronchoscopy. The nurse's explanation should focus on the insertion of a small tube through the nose or mouth into the bronchi to visualize the airways. This information helps the patient understand the basic process and what to expect during the procedure. Choice B is incorrect as bronchoscopy does not involve breathing a radioactive substance to show diseased areas in the lungs. Choice C is also incorrect as there is no requirement to drink a thick white liquid for bronchoscopy. Choice D is incorrect as dye injection is not a standard part of bronchoscopy, and asking about allergies to dye is irrelevant in this context.
Question 8 of 9
The nurse is caring for a patient with HIV. Which of the following foods would the nurse teach the patient is safe to eat to reduce the risk of infection?
Correct Answer: C
Rationale: The correct answer is C: Cooked vegetables. Cooking vegetables helps to kill harmful bacteria and parasites that may pose a risk of infection to an immunocompromised individual like a patient with HIV. Raw fruits (A) and raw vegetables (B) may carry pathogens that can be dangerous for someone with a weakened immune system. Caesar dressing (D) may contain raw eggs, which also pose a risk for infection. Therefore, choosing cooked vegetables is the safest option to reduce the risk of infection for the patient with HIV.
Question 9 of 9
Which patient should be monitored most closely for dehydration?
Correct Answer: A
Rationale: The correct answer is A, the 50-year-old with an ileostomy, should be monitored most closely for dehydration. Patients with an ileostomy have a higher risk of dehydration due to increased fluid loss through the stoma. Monitoring their fluid intake, output, electrolyte levels, and signs of dehydration is crucial to prevent complications. The other choices are less likely to experience severe dehydration compared to the patient with an ileostomy. The 72-year-old with diabetes mellitus may be at risk for dehydration, but it is not as high a risk as the patient with an ileostomy. The 19-year-old with chronic asthma and the 28-year-old with a broken femur are not as directly related to dehydration compared to the patient with an ileostomy.