ATI RN
Nursing Process Test Bank Questions
Question 1 of 9
A patient was rushed to the ER because of difficulty in urination. He was diagnosed then as a cse of benign prostate hyperthropy (BPH) and was advised by the doctor to undego transurethral resection of prostate (TURP). Based on the urgency of the surgery, the nurse classifies this condition as:
Correct Answer: A
Rationale: The correct answer is A: emergency. In this scenario, the patient is experiencing difficulty in urination due to benign prostate hyperplasia (BPH), a condition that can lead to serious complications like acute urinary retention. Transurethral resection of the prostate (TURP) is a surgical procedure that is used to relieve the obstruction caused by BPH. Given the urgency of the situation and the potential for acute complications, the surgery needs to be performed immediately to prevent further harm to the patient's health. Classifying this condition as an emergency ensures prompt intervention and prioritizes the patient's well-being. Summary: - B: C.urgent (not correct): While the surgery is time-sensitive, it does not require immediate intervention like in an emergency situation. - C: elective (not correct): Elective surgeries are planned in advance and are not typically performed in urgent situations like this one. - D: required (not correct): While the surgery is necessary for the patient's condition
Question 2 of 9
A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?
Correct Answer: C
Rationale: The correct answer is C because it shows a positive self-perception and self-acceptance. By choosing the dress based on how it complements her eyes, the patient demonstrates a focus on her own preferences and self-image rather than external validation or criticism. This indicates progress towards accepting her body image. A: Choice A indicates concern about others' opinions, which shows a lack of self-assurance and reliance on external validation. B: Choice B reflects negative body image and self-criticism, indicating a lack of acceptance. D: Choice D is focused on a future event, suggesting avoidance or delay in addressing the current body image issues.
Question 3 of 9
A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?
Correct Answer: B
Rationale: The correct answer is B: Ask her to demonstrate her ability to ambulate. This response is best because it allows the nurse to assess the patient's actual ability to walk safely to the bathroom. By observing her, the nurse can ensure her safety and prevent potential falls. This approach also respects the patient's autonomy while prioritizing her safety. Incorrect responses: A: Allowing her to ambulate unassisted solely for positive self-esteem overlooks the importance of assessing her actual capability and ensuring safety. C: Explaining that assistance will always be available may not address the immediate need for assessment and safety. D: Asking another staff member to assist without assessing the patient's ability herself does not allow the nurse to directly evaluate the patient's safety and independence.
Question 4 of 9
Which action will the nurse take after the plan of care for a patient is developed?
Correct Answer: B
Rationale: The correct answer is B because after developing a plan of care, the nurse must communicate it to all healthcare professionals involved in the patient's care to ensure everyone is aware of the plan and can collaborate effectively. This promotes continuity of care and prevents errors. Choice A is incorrect because the plan of care should not be placed in the chart to avoid tampering; it should be easily accessible for updates. Choice C is incorrect as filing in the administration office is unnecessary for routine care. Choice D is incorrect as sending the plan to quality assurance is not the immediate next step after developing the plan.
Question 5 of 9
Which of the following would the nurse teach the patient is the most common site for ear infections?
Correct Answer: B
Rationale: The correct answer is B, Middle ear. This is because the middle ear is the most common site for ear infections due to its anatomy, including the Eustachian tube that can easily become blocked, leading to fluid buildup and infection. The outer ear (A) is less susceptible to infections, while the inner ear (C) and semicircular canal (D) are not typically involved in ear infections, as they are more related to balance and hearing functions rather than infection susceptibility.
Question 6 of 9
When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?
Correct Answer: A
Rationale: The correct answer is A: A normal finding. The Darwin tubercle is a small, painless, bony nodule at the helix of the ear and is considered a normal anatomical variation. It is present in a significant portion of the population, regardless of age. It does not indicate any pathology or abnormality. Choices B, C, and D are incorrect because the presence of a Darwin tubercle is not indicative of any abnormality, and it is not limited to older adults.
Question 7 of 9
Which of the following is an intraoperative outcome for a patient undergoing an inguinal hernia repair?
Correct Answer: C
Rationale: The correct answer is C: Maintains skin integrity. During inguinal hernia repair surgery, maintaining skin integrity is crucial to prevent infection and ensure proper wound healing. This outcome focuses on the physical aspect of the surgery and reflects the patient's skin condition postoperatively. Verbalizing fears (A) addresses emotional concerns, demonstrating leg exercises (B) is related to postoperative rehabilitation, and explaining deep breathing exercises (D) targets respiratory function, none of which directly assess the intraoperative outcome of skin integrity.
Question 8 of 9
The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:
Correct Answer: B
Rationale: The correct answer is B: "Good oral hygiene is needed, including brushing and flossing." This is because phenytoin (Dilantin) can cause gingival hyperplasia, a side effect that leads to overgrowth of gum tissue. Good oral hygiene practices, such as regular brushing and flossing, can help prevent or minimize this side effect. Choice A is incorrect because alcohol is contraindicated while taking phenytoin as it can increase the risk of side effects and decrease the effectiveness of the medication. Choice C is incorrect because medication doses should never be self-adjusted without consulting a healthcare provider, as this can lead to ineffective treatment or potential harm. Choice D is incorrect because the timing of the morning dose in relation to drawing a serum drug level is not relevant to the client's understanding of medication instructions and does not address the specific side effect of gingival hyperplasia associated with phenytoin.
Question 9 of 9
Which immunoglobulin is specific to an allergic response?
Correct Answer: B
Rationale: The correct answer is B: IgE. IgE is specific to allergic responses as it binds to mast cells and basophils, triggering the release of histamine and other inflammatory mediators. IgA is more involved in mucosal immunity, IgG is involved in long-term immunity and opsonization, and IgM is the primary antibody in the primary immune response. IgB is not a known immunoglobulin. Therefore, IgE is the specific immunoglobulin associated with allergic responses due to its role in mediating hypersensitivity reactions.