ATI RN
Nursing Process Test Bank Questions
Question 1 of 9
A woman with pelvic inflammatory disease complains of lower abdominal pain. Which action should the nurse take first?
Correct Answer: B
Rationale: The correct action is to administer antibiotics as ordered first because pelvic inflammatory disease is caused by an infection, usually from sexually transmitted organisms. Administering antibiotics promptly is crucial to prevent further complications and treat the underlying infection. This helps to alleviate the source of the pain. Rating pain severity, administering analgesics, and patient education are important but should come after addressing the infection to prevent worsening of the condition.
Question 2 of 9
At the present time, the best treatment for cancer is complete __________ before metastasis occurs:
Correct Answer: C
Rationale: The correct answer is C: Surgical removal. Surgical removal of the cancerous tumor is the best treatment before metastasis because it physically removes the cancer cells. Chemotherapy and radiation are used to treat cancer after it has spread, not as the primary treatment. Choice D is incorrect because not all types of cancer can be effectively treated with all three options.
Question 3 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 4 of 9
Which of the ff should the nurse include in the teaching plan of a client with acute bronchitis?
Correct Answer: B
Rationale: The correct answer is B: Washing the hands frequently. This is important for preventing the spread of infection, which is crucial in acute bronchitis. By washing hands frequently, the client can reduce the risk of transmitting the infection to others and prevent reinfection. A: Not coughing frequently - While managing cough is important, it is not the most crucial aspect in the teaching plan for acute bronchitis. C: Consuming adequate calories - While nutrition is important for overall health, it is not specifically related to the management of acute bronchitis. D: Encouraging a semi-Fowler’s position - While this position can help with breathing, it is not the most important aspect in the teaching plan for acute bronchitis.
Question 5 of 9
The client is a type II DM patient. The client asks the nurse what is the primary reason a type II diabetic does not usually develop diabetic ketoacidosis?
Correct Answer: C
Rationale: Rationale for Choice C (Correct answer): - In type II DM, there is some insulin present but it is insufficient to meet the body's needs. - Without sufficient insulin, the body turns to breaking down protein and fatty acids for energy. - This leads to the formation of ketones, which can lead to diabetic ketoacidosis (DKA). - Therefore, the primary reason a type II diabetic does not usually develop DKA is due to insufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs. Summary of other choices: - Choice A is incorrect because there is some insulin available in type II DM, though it may be insufficient. - Choice B is incorrect as type II diabetics do have fat and protein reserves. - Choice D is incorrect as insufficient serum glucose concentrations do not directly relate to the development of DKA in type II DM.
Question 6 of 9
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
Correct Answer: B
Rationale: The correct answer is B because conducting the interview in a quiet environment, like the waiting area with the television turned off, reduces background noise and distractions for the patient with a hearing deficit. This allows for better communication and understanding. A: Conducting the interview in the patient's room with the door closed may still have distractions or noise from outside the room. C: Conducting the interview in the patient's room before administration of pain medication does not address the issue of reducing background noise for better communication. D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional distractions and noise, making it harder for the patient with a hearing deficit to communicate effectively.
Question 7 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 8 of 9
An African client has been diagnosed with Osteomyelitis. The nurse expects to assess which of the following?
Correct Answer: C
Rationale: The correct answer is C: positive wound cultures. Osteomyelitis is an infection of the bone that is typically diagnosed through wound cultures. This assessment helps to identify the causative organism and guide appropriate treatment. Choices A and D are not typical findings in osteomyelitis. Choice A describes symptoms of poor circulation which are not specific to osteomyelitis. Choice B, decreased white blood cell count, is typically not seen in the presence of an infection like osteomyelitis.
Question 9 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.