ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 5
An adult is on a clear liquid diet. Which food item can be offered/
Correct Answer: C
Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids and foods that are liquid at room temperature. Jello meets this criteria as it is a clear, easily digestible food. Milk (A) is not allowed on a clear liquid diet due to its opaque nature. Orange juice (B) contains pulp and is not considered clear. Ice cream (D) is a solid food and not permitted on a clear liquid diet. Therefore, Jello is the most suitable option for someone on a clear liquid diet.
Question 2 of 5
A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
Correct Answer: A
Rationale: The correct answer is A: A-positive blood to an A-negative client. This is because in ABO blood typing, individuals with blood type A have anti-B antibodies in their plasma. Therefore, if A-positive blood (which contains the A antigen) is given to an A-negative client (who has anti-A antibodies), there is a high risk of an acute hemolytic reaction due to the antibodies attacking the transfused blood cells. Choices B, C, and D are incorrect because they do not involve a mismatch of ABO blood types that would lead to a significant risk of acute hemolytic reaction. In choice B, O-positive blood can be safely transfused to an A-positive client as O blood is considered the universal donor. In choice C, O-negative blood can be safely given to an O-positive client as O-negative blood is compatible with all blood types. In choice D, B-positive blood can be safely administered to an AB-positive client as the AB blood type can receive both
Question 3 of 5
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Alteration in tissue perfusion related to bleeding and diminished blood flow. Disseminated intravascular coagulation (DIC) is a condition where blood clots form throughout the body, leading to both bleeding and clotting. This can result in decreased blood flow to tissues, causing tissue perfusion issues. Explanation: 1. Option A: Risk for increased cardiac output related to fluid volume excess is incorrect because DIC can lead to bleeding, causing a decrease in blood volume and potentially decreasing cardiac output. 2. Option B: Disturbed sensory perception related to bleeding into tissues is incorrect as DIC primarily affects blood clotting and bleeding, not sensory perception. 3. Option D: Risk for aspiration related to constriction of the respiratory musculature is incorrect as DIC does not directly cause constriction of respiratory muscles, but rather impacts the clotting and bleeding processes in the body. In summary, the correct answer is C because DIC can lead to altered tissue perfusion
Question 4 of 5
Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
Correct Answer: B
Rationale: The correct answer is B: Acute pain. NANDA-I (North American Nursing Diagnosis Association International) approves standardized nursing diagnoses to guide nursing care. Acute pain is a NANDA-I approved diagnosis as it helps identify and address a patient's pain experience. It is specific, measurable, and relevant for care planning. Sore throat (A) is a symptom, not a diagnosis. Sleep apnea (C) and heart failure (D) are medical conditions, not nursing diagnoses. The focus of nursing care plans is on identifying patient responses to health conditions, which is why acute pain is the most appropriate choice.
Question 5 of 5
A patient is unable to control his bowels ff. a subarachnoid hemorrhage. Which intervention by the nurse can help reduce episodes of bowel incontinence?
Correct Answer: C
Rationale: The correct answer is C: Toilet the patient according to his pre-illness schedule, whether or not he feels the urge. This intervention helps establish a routine for bowel movements, which can aid in reducing episodes of bowel incontinence. By following the patient's pre-illness schedule, the nurse can help regulate bowel movements and prevent accidents. A: Asking the patient frequently if he has to have a bowel movement may not address the underlying issue of bowel incontinence. B: Placing incontinence pads on the patient's bed and chair is a reactive measure and does not address the root cause of the issue. D: Taking care not to embarrass the patient when incontinent episodes occur is important for emotional support but does not directly address reducing episodes of bowel incontinence.
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