ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 5
An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first?
Correct Answer: A
Rationale: The correct answer is A: The client’s airway should be assessed first. This is because airway management is the top priority in any emergency situation to ensure the patient can breathe. Without a patent airway, the patient's oxygenation and ventilation will be compromised, leading to serious complications or death. Choices B, C, and D are incorrect because assessing the airway takes precedence over determining the reason for admission, reviewing medications, or assessing past medical history in an unconscious patient. These other assessments are important but not as critical as securing the airway to maintain the patient's breathing and oxygenation.
Question 2 of 5
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to gather relevant information and focus the interview on the patient's needs. This step helps establish rapport and ensures the patient is actively involved in the conversation. Incorrect Choices: A: Beginning with introductions is important, but after setting the agenda, it is more crucial to address the patient's concerns. C: Explaining that the interview will be over in a few minutes is not appropriate as it may rush the patient and hinder open communication. D: Telling the patient about administering medications in 1 hour is not relevant at this stage and does not address the patient's immediate needs.
Question 3 of 5
Which of the following would the nurse identify as an abnormal finding?
Correct Answer: C
Rationale: The nurse would identify platelets at 115,000/ul as an abnormal finding because it is below the normal range of 150,000-450,000/ul. Low platelet count can lead to increased bleeding risk. RBC count and hematocrit levels are within normal ranges, making them normal findings. Option D is incorrect as platelets are abnormal.
Question 4 of 5
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 5 of 5
A client with Hashimoto’s thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Because of the client’s cardiac history, the nurse would expect that the client’s initial dose for the thyroid replacement would be which of the following?
Correct Answer: A
Rationale: The correct answer is A: 25 g/day, initially. In this scenario, the client with Hashimoto's thyroiditis and a history of cardiac issues requires a cautious approach due to the risk of exacerbating cardiac conditions with thyroid hormone replacement. Starting with a low dose of 25 µg/day allows for careful monitoring of the client's response and prevents potential adverse effects on the cardiovascular system. Summary: B: Delayed until after thyroid surgery - Not appropriate as the client requires thyroid replacement therapy for Hashimoto's thyroiditis. C: 100 µg/day, initially - Too high of an initial dose and may lead to adverse cardiovascular effects. D: Initiated before thyroid surgery - Not relevant to the client's situation as there is no indication for thyroid surgery mentioned in the question.
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