ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 9
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for the patient with a right femur fracture stabilized in a full leg cast is "Acute pain" (Choice C). The rationale for this is as follows: 1. The patient is experiencing moderate discomfort due to the fracture and immobilization in the cast, indicating a need for pain management. 2. Acute pain is a priority in this situation as it can impact the patient's comfort, mobility, and overall recovery. 3. Managing pain effectively is crucial for promoting healing, preventing complications, and improving the patient's quality of life. 4. Posttrauma syndrome (Choice A) may be a consideration in the long term but is not the immediate priority. Constipation (Choice B) is not the most pertinent nursing diagnosis in this scenario. Anxiety (Choice D) may be present but addressing pain is more urgent and directly related to the patient's current condition.
Question 2 of 9
A male client who is HIV positive is admitted to the hospital with a diagnosis of Pneumocystis carinii pneumonia. His live-in partner has accompanied him. During the history interview, the nurse is aware of feeling a negative attitude about the client’s lifestyle, what action is most appropriate?
Correct Answer: B
Rationale: The correct answer is B: Discuss the negative feelings with the client. This is the most appropriate action as it allows the nurse to address and manage their own biases and attitudes towards the client in a professional and constructive manner. By acknowledging and discussing these feelings with the client, the nurse can work towards providing non-judgmental care and fostering a therapeutic relationship. A: Sharing these feelings with the client is not appropriate as it can harm the nurse-client relationship and potentially lead to discrimination. C: Developing a written interview form is not addressing the immediate issue of the nurse's negative attitude towards the client. D: Avoiding eye contact with the client is unprofessional and does not address the underlying issue of the nurse's negative feelings.
Question 3 of 9
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
Correct Answer: C
Rationale: The correct answer is C. Rolling Mr. Gabatan on his abdomen, placing a pad under his head, and covering him with any material available is the appropriate action. This position helps protect his airway and prevents potential complications from a possible spinal injury. It also allows for better assessment of his condition by healthcare professionals. Choice A is incorrect because leaving Mr. Gabatan on his back and instructing him to move can worsen any spinal injury he may have sustained. Choice B is incorrect because raising him to a sitting position can also exacerbate his condition. Choice D is incorrect because moving him without proper stabilization can lead to further injury.
Question 4 of 9
The nurse is aware that in communicating with an elderly client, the nurse will
Correct Answer: B
Rationale: The correct answer is B: Use a low-pitched voice. This is because elderly individuals often experience age-related hearing loss, especially in high frequencies. Using a low-pitched voice helps improve the clarity and understanding of communication. Incorrect choices: A: Leaning and shouting can be perceived as aggressive and disrespectful to the elderly client. C: Opening the mouth wide while talking does not enhance communication and might be seen as patronizing. D: Using a medium-pitched voice may still be difficult for the elderly client to hear clearly due to age-related hearing loss.
Question 5 of 9
Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:
Correct Answer: B
Rationale: The correct answer is B because encouraging the intake of low-sodium liquids like coffee or tea can worsen hyponatremia. Hyponatremia is a condition characterized by low sodium levels in the blood, so encouraging low-sodium liquids would further dilute the sodium levels. The other choices are correct interventions for hyponatremia: A) assessing for symptoms helps in monitoring the patient's condition, C) monitoring neurological status is crucial as hyponatremia can lead to neurological complications, and D) restricting tap water intake helps in managing fluid intake and preventing further dilution of sodium levels.
Question 6 of 9
When the nurse is reviewing a patient’s daily laboratory test results, which of the ff. electrolyte imbalances should the nurse recognize as predisposing the patient to digoxin toxicity?
Correct Answer: A
Rationale: Step-by-step rationale: 1. Digoxin toxicity can be potentiated by hypokalemia due to the risk of enhanced cardiac toxicity. 2. Hypokalemia can lead to increased sensitivity of cardiac cells to digoxin. 3. Low potassium levels can disrupt the sodium-potassium ATPase pump, enhancing digoxin's effects. 4. The nurse should recognize hypokalemia as a predisposing factor for digoxin toxicity. Summary: A: Hypokalemia is the correct answer as it enhances digoxin toxicity by affecting cardiac function. B: Hyponatremia does not directly predispose to digoxin toxicity. C: Hyperkalemia is not a predisposing factor and can actually counteract digoxin's effects. D: Hypernatremia is not directly related to digoxin toxicity.
Question 7 of 9
If the systolic BP is elevated and the diastolic BP is normal, the nurse recognizes that a patient is most likely to have which type of hypertension?
Correct Answer: B
Rationale: The correct answer is B: Isolated systolic hypertension. This is because in isolated systolic hypertension, the systolic blood pressure is elevated while the diastolic blood pressure remains normal. This condition is common in older adults and is often related to aging and stiffening of the arteries. Primary hypertension (A) typically involves both elevated systolic and diastolic pressures. Secondary hypertension (C) is caused by an underlying condition. Hypertensive emergency (D) is characterized by severe elevations in both systolic and diastolic pressures with acute target organ damage.
Question 8 of 9
Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
Correct Answer: A
Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank. Rationale: 1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway. 2. Oxygen tank: To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted. Summary of incorrect choices: B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy. C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation. D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.
Question 9 of 9
Alex is taking carbamazepine (tegretol) for seizure disorder. He should be monitored for which of the following potential complications?
Correct Answer: D
Rationale: The correct answer is D: leukocytosis. Carbamazepine can cause bone marrow suppression, leading to leukocytosis. Monitoring for elevated white blood cell count is essential to detect this potential complication early. A: Adult respiratory distress syndrome is not a common complication of carbamazepine. B: Elevated levels of phenytoin is not a direct complication of carbamazepine use. C: Diplopia is a common side effect of carbamazepine, not a potential complication like leukocytosis.