ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 9
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 2 of 9
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self- examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
Correct Answer: C
Rationale: The correct answer is C: Non-mobile mass with irregular edges delineated. This finding strongly suggests cancer as non-mobile masses with irregular edges are characteristic of malignant tumors. Cancerous lumps tend to be fixed in place due to involvement of surrounding tissues. Irregular edges indicate potential invasive growth. Choices A and B describe characteristics more commonly associated with benign masses. Eversion of the nipple is concerning for cancer but not specific enough to strongly suggest malignancy. Choice D indicates absence of lymph node involvement, which is not directly related to the characteristics of the breast lump.
Question 3 of 9
Nursing intervention during the lumbar puncture procedure includes:
Correct Answer: D
Rationale: Step 1: Monitoring Mrs. GC's color, pulse, and respiration is important to assess for any signs of distress during the procedure. Step 2: Labeling all laboratory specimens in numerical order ensures accurate identification and prevents errors in specimen handling. Step 3: Positioning Mrs. GC on her side with knees drawn up to her chest helps maintain proper spinal alignment and reduces the risk of complications. Summary: Option D is correct because all the interventions mentioned are crucial for ensuring patient safety and procedural success. Options A, B, and C are incorrect individually as they each address only one aspect of the procedure, whereas the correct answer encompasses all necessary interventions.
Question 4 of 9
Appropriate nursing interventions for J.E. would be
Correct Answer: A
Rationale: The correct answer is A because it includes essential nursing interventions for a patient with head injuries like J.E. Skin care and position changes every 2 hours help prevent pressure ulcers. Maintaining alignment of extremities prevents contractures. Respiratory exercises aid in lung function. Option B lacks the crucial aspect of maintaining extremity alignment. Option C includes teaching the use of an overhead trapeze, which may not be appropriate for J.E. Option D lacks the instruction to maintain extremity alignment, which is crucial for preventing contractures in patients with head injuries.
Question 5 of 9
The nurse knows that a client understands a low residue diet when he selects which of the following from the menu?
Correct Answer: A
Rationale: The correct answer is A: Rice and lean chicken. A low residue diet aims to reduce fiber intake to ease digestion. Rice and lean chicken are low in fiber and easy to digest. Pasta with vegetables (B) contains high-fiber vegetables. Strawberry pie (C) is high in fiber due to fruit and crust. Tuna casserole (D) may contain high-fiber ingredients like noodles and vegetables. Therefore, A is the best choice for a low residue diet.
Question 6 of 9
An adult has a central venous line. Which of the following should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D because monitoring for signs of infection, air embolus, and leakage/puncture are crucial in caring for a patient with a central venous line to prevent serious complications. Infections can lead to sepsis, air embolus can cause respiratory distress, and leakage/puncture can result in hemorrhage or damage to surrounding tissues. A: While a complete blood count and electrolytes may be important for monitoring the patient's overall health, they are not specific to the central venous line care. B: Regular chest x-rays are not necessary unless there are specific indications of line malposition or complications. C: Continuous infusion at a keep-vein-open rate is a standard practice but does not address the critical aspects of central line care mentioned in option D. Therefore, monitoring for signs of infection, air embolus, and leakage/puncture is the most essential component of the plan of care for a patient with a central venous line.
Question 7 of 9
. During the first 24 hours after a client is diagnosed with Addisonian crisis, which of the following should the nurse perform frequently?
Correct Answer: D
Rationale: The correct answer is D, assess vital signs, as it is crucial to monitor the client's hemodynamic stability and response to treatment during the critical initial 24 hours of Addisonian crisis. Vital signs such as blood pressure, heart rate, and respiratory rate provide valuable information about the client's condition and response to therapy. Weighing the client (choice A) and testing urine for ketones (choice C) may be important but not as immediately critical as monitoring vital signs. Administering oral hydrocortisone (choice B) is essential for treatment but does not require frequent administration within the first 24 hours.
Question 8 of 9
A Jewish client has been diagnosed with ulcerative colitis. A nursing diagnosis appropriate for a client who has ulcerative colitis is:
Correct Answer: A
Rationale: The correct answer is A: abdominal pain related to decreased peristalsis. Ulcerative colitis causes inflammation and ulcers in the colon, leading to abdominal pain due to decreased peristalsis. This impairs the movement of stool through the colon, resulting in pain. Choice B is incorrect as diarrhea is a common symptom of ulcerative colitis, not hyperosmolar intestinal contents. Choice C is incorrect as ulcerative colitis often leads to diarrhea and not fluid volume excess. Choice D is incorrect as activity intolerance is not directly related to ulcerative colitis, whereas abdominal pain is a common symptom associated with the condition.
Question 9 of 9
The patient develops a low-grade fever 18 hours post-operatively and has diminished breath sounds. Which of the following actions is most appropriate for the nurse to take to prevent complications? i.Administer antibiotics iv.Decrease fluid intake ii.Encourage coughing and deepbreathing v.Ambulate patient as ordered iii.Administer acetaminophen (Tylenol)
Correct Answer: A
Rationale: The correct answer is A: 2 and 5. Diminished breath sounds indicate possible atelectasis or pneumonia post-operatively, making coughing and deep breathing (2) and ambulation (5) crucial to prevent complications. Decreasing fluid intake (iv) can lead to dehydration, worsening the situation. Administering antibiotics (i) without further assessment may not be necessary at this point. Acetaminophen (iii) can help with fever but does not address the underlying respiratory issue.