ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
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 5
What is the last step when inserting an IV cannula?
Correct Answer: A
Rationale: The correct answer is A: Secure the cannula with tape. This is the last step in inserting an IV cannula to ensure it stays in place and prevents dislodgement or movement. Securing the cannula with tape helps maintain proper positioning and prevents accidental removal. Documenting the insertion site, date, and type of cannula used (B) is important but typically done earlier in the process. Assessing the site (C) should be done before securing the cannula to ensure proper placement. Placing a sterile dressing over the insertion site (D) is also important, but it usually comes before securing the cannula with tape to maintain a clean and sterile environment.
Question 3 of 5
Blood cells are formed in the:
Correct Answer: C
Rationale: The correct answer is C: Bone marrow. Blood cells are primarily formed in the bone marrow through a process called hematopoiesis. The bone marrow contains stem cells that differentiate into various types of blood cells, including red blood cells, white blood cells, and platelets. Arterioles are small blood vessels that carry blood away from the heart, not involved in blood cell formation. Lymphoid tissue plays a role in immune function but not in blood cell production. Muscle tissue is primarily responsible for movement and does not have a role in blood cell formation. Therefore, the bone marrow is the correct answer as it is the main site of blood cell production in the body.
Question 4 of 5
A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
Correct Answer: D
Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery. Explanation for other choices: A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed. B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain. C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.
Question 5 of 5
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.
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