ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
An adult has a central venous line. Which of the following should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D because monitoring for signs of infection, air embolus, and leakage/puncture are crucial in caring for a patient with a central venous line to prevent serious complications. Infections can lead to sepsis, air embolus can cause respiratory distress, and leakage/puncture can result in hemorrhage or damage to surrounding tissues. A: While a complete blood count and electrolytes may be important for monitoring the patient's overall health, they are not specific to the central venous line care. B: Regular chest x-rays are not necessary unless there are specific indications of line malposition or complications. C: Continuous infusion at a keep-vein-open rate is a standard practice but does not address the critical aspects of central line care mentioned in option D. Therefore, monitoring for signs of infection, air embolus, and leakage/puncture is the most essential component of the plan of care for a patient with a central venous line.
Question 2 of 5
Appropriate nursing interventions for J.E. would be
Correct Answer: A
Rationale: The correct answer is A because it includes essential nursing interventions for a patient with head injuries like J.E. Skin care and position changes every 2 hours help prevent pressure ulcers. Maintaining alignment of extremities prevents contractures. Respiratory exercises aid in lung function. Option B lacks the crucial aspect of maintaining extremity alignment. Option C includes teaching the use of an overhead trapeze, which may not be appropriate for J.E. Option D lacks the instruction to maintain extremity alignment, which is crucial for preventing contractures in patients with head injuries.
Question 3 of 5
The nurse is aware that in communicating with an elderly client, the nurse will
Correct Answer: B
Rationale: The correct answer is B: Use a low-pitched voice. This is because elderly individuals often experience age-related hearing loss, especially in high frequencies. Using a low-pitched voice helps improve the clarity and understanding of communication. Incorrect choices: A: Leaning and shouting can be perceived as aggressive and disrespectful to the elderly client. C: Opening the mouth wide while talking does not enhance communication and might be seen as patronizing. D: Using a medium-pitched voice may still be difficult for the elderly client to hear clearly due to age-related hearing loss.
Question 4 of 5
Which neurotransmitter mediates the sympathetic response?
Correct Answer: A
Rationale: The correct answer is A: Norepinephrine. Norepinephrine is the primary neurotransmitter that mediates the sympathetic response. It is released by sympathetic nerve endings and acts on adrenergic receptors in various target organs to initiate the "fight or flight" response. Prostaglandin, acetylcholine, and serotonin do not directly mediate the sympathetic response and are involved in different physiological processes.
Question 5 of 5
The nurse notes frequent muscle twitching when collecting admission data on a patient admitted for increasing muscle weakness. Which of the ff. terms should the nurse use to document this?
Correct Answer: A
Rationale: The correct answer is A: Fasciculations. Fasciculations are involuntary muscle twitches commonly seen with neurological conditions like motor neuron disease. In this case, the patient's muscle weakness and frequent muscle twitching indicate possible nerve damage. Chorea (B) is characterized by involuntary, jerky movements, not twitching. Atrophy (C) refers to muscle wasting, not twitching. Neuropathy (D) is a general term for nerve damage and does not specifically describe the muscle twitching seen in this patient.