ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 9
A patient visiting with family members in the waiting area tells the nurse “I don’t feel good, especially in the stomach.” What should the nurse do?
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to return to the room, so the nurse can inspect the abdomen. Rationale: 1. Patient safety: By examining the patient's abdomen, the nurse can assess for any signs of distress or potential medical issues. 2. Patient-centered care: It is essential to prioritize the patient's well-being by addressing their concerns promptly and appropriately. 3. Professional responsibility: Nurses are trained to assess and evaluate patient symptoms to provide necessary care and support. Summary: A: Requesting the family to leave does not address the patient's symptoms and may disrupt the patient's support system. C: Asking about bowel movements and offering food may not be appropriate if the patient is experiencing stomach discomfort. D: Offering food without proper assessment may worsen the patient's condition and is not recommended before a proper evaluation.
Question 2 of 9
Through which of the following does lymph return to the blood?
Correct Answer: D
Rationale: The correct answer is D: Subclavian veins. Lymph returns to the blood through the subclavian veins because they receive lymphatic drainage from the thoracic duct and right lymphatic duct. Lymphatic vessels merge into lymphatic ducts, which empty into the subclavian veins, allowing lymph to re-enter the bloodstream. The carotid arteries (A) carry oxygen-rich blood to the brain, the aorta (C) is the main artery of the body carrying oxygenated blood from the heart, and the inferior vena cava (B) returns deoxygenated blood from the lower body to the heart. Therefore, choices A, B, and C are incorrect as they are not involved in the return of lymph to the blood.
Question 3 of 9
A client asks the nurse what PSA is. The nurse should reply that is stands for:
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Prostate-specific antigen (PSA) is a protein produced by the prostate gland. It is primarily used to screen for prostate cancer by measuring the levels of PSA in the blood. PSA levels can help detect prostate cancer early. Therefore, choice A is the correct answer as it accurately describes PSA and its primary use. Summary of Incorrect Choices: B: Protein serum antigen is not a commonly known term in healthcare. There is no specific antigen called "protein serum antigen" used to determine protein levels. C: Pneumococcal strep antigen is a bacterial antigen that causes pneumonia, not related to PSA used in prostate cancer screening. D: Papanicolua-specific antigen is not a recognized term. The Papanicolaou test (Pap smear) is used for cervical cancer screening, not a specific antigen like PSA.
Question 4 of 9
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to focus the interview on the patient's needs. This step helps in gathering important information and establishing rapport. Introductions are usually done at the beginning of the interview, so it is not the next step. Explaining that the interview will be over in a few minutes can create anxiety and hinder open communication. Telling the patient about administering medications in 1 hour is not relevant at this point in the interview.
Question 5 of 9
Which of the ff. is the best explanation of emphysema for a newly diagnosed patient?
Correct Answer: B
Rationale: The correct answer is B because emphysema is characterized by the destruction of the alveoli walls, leading to a loss of elasticity in the lungs. This results in air becoming trapped in the lungs, making it difficult to exhale properly. Explanation for why the other choices are incorrect: A: Inflamed bronchioles causing secretions describe bronchitis, not emphysema. C: Damage to the blood supply isn't a primary feature of emphysema; it's more about lung tissue destruction. D: Large dilated sacs of sputum in the lungs is not an accurate description of emphysema; it's more related to bronchiectasis.
Question 6 of 9
The following are known to be causes of hepatitis except:
Correct Answer: C
Rationale: The correct answer is C: bacteria. Hepatitis is primarily caused by viruses (such as Hepatitis A, B, C), toxins (like alcohol or certain medications), and chemicals/drugs. Bacteria do not typically cause hepatitis as it is a viral infection that affects the liver. Therefore, choice C is the exception among the listed causes. Viruses directly target liver cells, toxins can damage the liver, and certain chemicals/drugs can lead to liver inflammation. Hence, bacteria do not play a significant role in causing hepatitis.
Question 7 of 9
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
Correct Answer: C
Rationale: The correct answer is C: Health promotion. The nurse wrote a diagnosis related to enhancing the patient's urinary elimination abilities through self-catheterization, which focuses on promoting the patient's health and well-being. The Readiness for enhanced urinary elimination diagnosis indicates the patient's motivation and readiness to improve their urinary elimination abilities, aligning with the concept of health promotion. This type of diagnosis acknowledges the patient's potential for growth and improvement in their health status. Incorrect choices: A: Risk - This choice would be more appropriate if the diagnosis focused on potential complications or adverse events related to the patient's urinary elimination abilities. B: Problem focused - This choice would be suitable if the diagnosis identified an existing issue or problem with the patient's urinary elimination abilities that needed to be addressed. D: Collaborative problem - This choice would be relevant if the diagnosis required collaboration between healthcare providers to manage the patient's urinary elimination abilities effectively.
Question 8 of 9
Which nursing action is most appropriate for the weak patient with osteoporosis?
Correct Answer: B
Rationale: The correct answer is B: Ambulate with assistance. Ambulating helps prevent further bone loss and strengthens muscles, important for osteoporosis patients. Bedrest can worsen bone density loss. Encouraging fluids and providing a high-protein diet are important for overall health but do not directly address the weakness associated with osteoporosis.
Question 9 of 9
A female client age 66 is admitted ff a nephrolithomy. One of her laboratory tests reveals a urinary tract infection. Which would be the best nursing action in her case?
Correct Answer: C
Rationale: Correct Answer: C - Encourage fluid intake of 3000ml/day Rationale: Encouraging fluid intake of 3000ml/day helps to flush out bacteria from the urinary tract, reducing the risk of infection spread. Adequate hydration also prevents further stone formation. Incorrect Choices: A: Administering IV fluids and blood transfusions may not directly address the urinary tract infection. B: Administering narcotic analgesics may mask symptoms but not treat the root cause of the infection. D: Suggesting herbs or spices does not address the need for adequate fluid intake to manage the urinary tract infection.