ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 5
A patient reports on admission being “very sick” after taking erythromycin in the past. The patient is to receive erythromycin now. Which of the following actions should the nurse take regarding giving the antibiotic?
Correct Answer: B
Rationale: The correct answer is B: Do not give the antibiotic. This is because the patient has a history of being "very sick" after taking erythromycin in the past, indicating a potential allergic reaction or severe adverse effects. The nurse should not administer the antibiotic to prevent harm to the patient. Choice A is incorrect as it can lead to a repeat adverse reaction. Choice C, giving half the dose, still exposes the patient to potential harm. Choice D, discontinuing the antibiotic, is also incorrect as it implies the patient has already started the medication, which should not be the case given the history of adverse effects.
Question 2 of 5
An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first?
Correct Answer: A
Rationale: The correct answer is A: The client’s airway should be assessed first. This is because airway management is the top priority in any emergency situation to ensure the patient can breathe. Without a patent airway, the patient's oxygenation and ventilation will be compromised, leading to serious complications or death. Choices B, C, and D are incorrect because assessing the airway takes precedence over determining the reason for admission, reviewing medications, or assessing past medical history in an unconscious patient. These other assessments are important but not as critical as securing the airway to maintain the patient's breathing and oxygenation.
Question 3 of 5
A young male client visits a nurse with a complaint of chronic tension headaches. Which of the ff is the most appropriate nursing instruction to manage the client?
Correct Answer: C
Rationale: The correct answer is C: Counselling on alternate therapies. Chronic tension headaches may be exacerbated by stress or other psychological factors, making counseling an appropriate intervention. The nurse can explore relaxation techniques, stress management strategies, or cognitive-behavioral therapy to help the client manage their headaches. A: Instructing the client to monitor for signs of bruising or bleeding is unrelated to tension headaches and not a priority in this situation. B: Suggesting eating and swallowing techniques that reduce the potential for aspiration is not relevant to tension headaches and is not the most appropriate intervention. D: Advising the client to change sleeping positions frequently may help with other types of headaches but is not the most effective strategy for managing chronic tension headaches.
Question 4 of 5
The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
Correct Answer: C
Rationale: The correct answer is C: Take piroxicam with food or oral antacid. This instruction helps to reduce GI irritation by providing a protective barrier for the stomach lining. Piroxicam is known to cause GI upset due to its effect on prostaglandin synthesis. Taking it with food or an antacid can help minimize this side effect. Choice A (Space the administration every 4 hours) does not address the issue of GI irritation and is not a recommended strategy for preventing this side effect. Choice B (Use the drug for a short time only) is not a direct intervention to prevent GI upset and does not provide guidance on how to manage the side effect when taking the medication. Choice D (Decrease the piroxicam dosage) may not be necessary if the client can manage the side effects with the simple intervention of taking it with food or an antacid.
Question 5 of 5
The nurse is aware that multiple sclerosis is a progressive disease of the central nervous system characterized by:
Correct Answer: D
Rationale: Step 1: Multiple sclerosis (MS) is a progressive disease affecting the central nervous system. Step 2: Axon degeneration occurs in MS, leading to impaired nerve signal transmission. Step 3: MS is characterized by sclerosed patches, or plaques, in the nervous system. Step 4: Demyelination of the brain and spinal cord is a hallmark feature of MS. Step 5: Therefore, all of the above choices are correct as they accurately describe key features of MS.
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