ATI RN
Nursing Process Test Bank Questions
Question 1 of 9
A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? “This system can help medical students determine the cost of the care they provide to
Correct Answer: A
Rationale: The correct answer is A because the Nursing Interventions Classification (NIC) system is not designed to help medical students determine the cost of care. The NIC system focuses on standardizing and categorizing nursing interventions to improve communication, documentation, and patient care. Choice B is incorrect because it correctly identifies one of the benefits of using the NIC system - enhancing communication among nurses. Choice C is incorrect because it suggests a valid use of the NIC system for organizing orientation and explaining nursing interventions. Choice D is incorrect because it accurately states that the NIC system can improve documentation in the electronic health record, which is one of its purposes.
Question 2 of 9
While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client’s chart. Which of the following actions clearly demonstrates assessing?
Correct Answer: C
Rationale: The correct answer is C because asking the client if they are experiencing pain is a direct action of assessment. This step involves gathering information directly from the client to understand their condition and needs. By asking the client about pain, the nurse is actively assessing the client's well-being. A: The nurse bathing the client is not an action of assessment but rather a task related to providing care. B: The nurse documenting the incident is important for recording the event but does not directly involve assessing the client's condition. D: The nurse removing the wash basin is a task related to the physical care process and does not involve direct assessment of the client's well-being.
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
Seven girls were victims of food poisoning after eating the sandwiches served at snack time. Which of the following statement are true regarding food poisoning?
Correct Answer: D
Rationale: Step 1: Symptoms of food poisoning typically include salivation, cramping, nausea, vomiting, and diarrhea, so statement A is correct. Step 2: Food left unrefrigerated can lead to bacterial growth, making it more dangerous, so statement B is accurate. Step 3: Cooking can kill harmful organisms and stop the production of toxins, supporting statement C. Step 4: All three statements are true and collectively provide a comprehensive understanding of food poisoning, making option D the correct answer.
Question 5 of 9
A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?
Correct Answer: B
Rationale: The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications. A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances. C: Hyperchloremia is not a common concern in this scenario based on the given lab values. D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.
Question 6 of 9
Immunity to a disease after recovery is possible because the first exposure to the pathogen has stimulated the formation of which of the following?
Correct Answer: C
Rationale: The correct answer is C: Memory cells. After recovery from a disease, memory cells are formed as part of the adaptive immune response. These memory cells "remember" the pathogen and can mount a quicker and stronger immune response upon re-exposure. This results in immunity to the disease. Antigens (choice A) are substances that trigger the immune response but do not provide immunity on their own. Complement (choice B) is a group of proteins that enhance the immune response but do not directly lead to immunity. Natural killer cells (choice D) are part of the innate immune system and are not responsible for the specific memory response needed for immunity.
Question 7 of 9
A client metastatic ovarian cancer is prescribed cisplatin (Platinol). Before administering the first dose, the nurse reviews the client’s medication history for drugs that may interact with cisplatin. Which drug may cause significant interactions when given concomitantly with cisplatin?
Correct Answer: D
Rationale: The correct answer is D: An aminoglycoside. Aminoglycosides, such as gentamicin or amikacin, can interact with cisplatin by increasing the risk of nephrotoxicity and ototoxicity. Both cisplatin and aminoglycosides have the potential to cause kidney damage, and when used together, the risk of kidney toxicity is significantly increased. This interaction is due to the additive effects on the kidneys. Therefore, it is crucial to monitor renal function closely and adjust the dosages of these drugs accordingly to prevent severe adverse effects. Summary: A: Erythromycin - Erythromycin is not known to have significant interactions with cisplatin. B: A cephalosporin - Cephalosporins do not typically interact with cisplatin in a clinically significant manner. C: A tetracycline - Tetracyclines are not known to cause significant interactions with
Question 8 of 9
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
Correct Answer: B
Rationale: The correct answer is B: Maintaining a patent airway. This is the highest priority because the client with esophageal cancer is at risk for airway obstruction due to difficulty swallowing. Maintaining a patent airway ensures adequate oxygenation and ventilation, which are vital for the client's survival. Without a clear airway, the client may experience respiratory distress or failure. Body image, preventing injury, and ensuring adequate nutrition are important aspects of care but do not take precedence over maintaining a patent airway in this situation.
Question 9 of 9
Pulmonary complications are the most common problem in caring for AIDS patients. This is caused:
Correct Answer: B
Rationale: The correct answer is B: Pneumonia Carnii. Pulmonary complications in AIDS patients are commonly caused by Pneumocystis jirovecii (previously known as Pneumocystis carinii) pneumonia. This opportunistic infection targets the lungs of immunocompromised individuals, leading to severe respiratory issues. Kaposi's Sarcoma (A) is a cancer commonly seen in AIDS patients but does not directly cause pulmonary complications. Filterable Virus (C) is a vague term and not a known cause of pulmonary issues in AIDS patients. Staphylococcus bacteria (D) can cause infections in AIDS patients but is less common than Pneumocystis jirovecii pneumonia in causing pulmonary complications.