ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 9
A patient with a history of haemophilia A arrives in the emergency department complaining of a “funny feeling” in his elbow. The patient states that he thinks he is bleeding into the joint. Which response by the nurse is correct?
Correct Answer: B
Rationale: The correct response is B: Notify the physician immediately and expect an order for factor VIII. In a patient with hemophilia A, which is a deficiency of clotting factor VIII, bleeding into a joint can lead to serious complications. The nurse should notify the physician promptly because the patient may need factor VIII replacement therapy to stop the bleeding and prevent further damage. This is a medical emergency requiring timely intervention. Choices A, C, and D are incorrect: A: Palpating the elbow could exacerbate the bleeding and cause further damage. C: Ordering an x-ray would delay the crucial factor VIII replacement therapy needed to manage the bleeding. D: Applying heat can increase blood flow to the joint, worsening the bleeding.
Question 2 of 9
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
Correct Answer: B
Rationale: The correct answer is B: Reduced sneezing. Decongestants work by constricting blood vessels in the nasal passages, reducing swelling and congestion, which in turn can lead to a decrease in sneezing. Increased salivation (choice A) is not a typical effect of decongestants. Increased tearing (choice C) is more commonly associated with allergies or irritants. Headache (choice D) can be a side effect of decongestants due to their impact on blood vessels, but it does not necessarily indicate effectiveness in treating allergic rhinitis.
Question 3 of 9
Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?
Correct Answer: D
Rationale: The correct answer is D because using two pillows to raise the head can increase the risk of venous stasis and thrombosis in a client with polycythemia vera. This condition involves an increased production of red blood cells, leading to thicker blood and potential clot formation. Elevating the head too much can impede blood flow, exacerbating the risk of clotting. Choices A, B, and C are all appropriate statements indicating good self-care practices and physical activity, which are beneficial for clients with polycythemia vera to improve circulation and overall health.
Question 4 of 9
An oncology nurse educator is speaking to a women’s group about breast cancer. Questions and comments from the audience reveal a misunderstanding of some aspects of the disease. Various members of the audience have made all of the following statements. Which one is accurate?
Correct Answer: D
Rationale: The correct answer is D: Men can develop breast cancer. This is accurate because although breast cancer is more common in women, men can also develop the disease due to the presence of breast tissue in their bodies. This is a crucial point to emphasize to raise awareness about breast cancer among men. Incorrect choices: A: Mammography is not the most reliable method for detecting breast cancer, as it may not detect all types of breast cancer. B: Breast cancer is not the leading killer of women of childbearing age, as there are other leading causes of death in this age group. C: Breast cancer does not always require a mastectomy; treatment options vary depending on the individual case. Summary: Choice D is correct as it highlights the important fact that men can also develop breast cancer, which is often overlooked. Choices A, B, and C are incorrect due to inaccuracies or oversimplifications of the facts related to breast cancer detection, statistics, and treatment.
Question 5 of 9
An adult has a central line in his right subclavian vein. The nurse is to change the tubing. Which of the following should be done?
Correct Answer: C
Rationale: The correct answer is C: Close the roller clamp on the new tubing after priming it. This step ensures that the tubing is primed with the solution and ready for use while preventing air from entering the central line. Option A is incorrect because using the present solution may introduce contamination. Option B is incorrect as connecting tubing before running fluid can introduce air into the line. Option D is incorrect as positioning the client on the right side does not prevent air embolism during tubing change.
Question 6 of 9
A client who is HIV positive should have the mouth examined for which oral problem common associated with AIDS?
Correct Answer: B
Rationale: The correct answer is B: Creamy white patches. These patches are indicative of oral thrush, a common fungal infection seen in individuals with weakened immune systems like those with AIDS. This infection is caused by Candida albicans. It presents as white patches on the tongue, inner cheeks, or roof of the mouth. Halitosis (A) is bad breath, not specific to AIDS. Carious teeth (C) refers to cavities, not directly related to AIDS. Swollen lips (D) can be a symptom of various oral conditions, but not specific to AIDS. In summary, creamy white patches are a characteristic oral problem associated with AIDS due to opportunistic infections like oral thrush.
Question 7 of 9
Which assessment finding would prompt the Rn to suspect compartment syndrome in a patient with a long leg cast?
Correct Answer: C
Rationale: The correct answer is C: severe, unrelieved pain. Compartment syndrome is characterized by increased pressure within a muscle compartment leading to decreased blood flow and tissue damage. Severe, unrelieved pain is a hallmark sign as the pressure builds up. Weak movement of the patient's toes (choice A) could indicate nerve damage but is not specific to compartment syndrome. Decreased pedal pulses (choice B) could suggest vascular compromise but are not specific to compartment syndrome. Presence of foot pallor (choice D) could indicate poor circulation but is not a definitive sign of compartment syndrome.
Question 8 of 9
To return a patient with hyponatremia to normal sodium levels, it is safer to restrict fluid intake than to administer sodium:
Correct Answer: C
Rationale: Step 1: Hyponatremia is an electrolyte imbalance characterized by low sodium levels in the blood. Step 2: Restricting fluid intake helps prevent further dilution of sodium in the blood, aiding in correcting hyponatremia. Step 3: Administering sodium can lead to rapid correction, risking osmotic demyelination syndrome. Step 4: Choice C is correct as it aligns with the goal of managing hyponatremia by preventing fluid overload symptoms. Summary: A, B, and D are incorrect as they do not directly address the primary concern of correcting low sodium levels in hyponatremia.
Question 9 of 9
The nurse is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?
Correct Answer: B
Rationale: The correct answer is B: 7 to 14 days. Marrow suppression from floxuridine typically occurs 1-2 weeks after administration due to its effects on rapidly dividing cells in the bone marrow. This is known as the nadir period. Choices A, C, and D are incorrect because 24 hours is too soon for noticeable effects, 2 to 4 days is too short for the nadir period, and 21 to 28 days is too long for the onset of marrow suppression. The correct choice aligns with the expected timeframe for floxuridine's impact on bone marrow function.