ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 9
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 9
A client asks the nurse what PSA is. The nurse should reply that is stands for:
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Prostate-specific antigen (PSA) is a protein produced by the prostate gland. It is primarily used to screen for prostate cancer by measuring the levels of PSA in the blood. PSA levels can help detect prostate cancer early. Therefore, choice A is the correct answer as it accurately describes PSA and its primary use. Summary of Incorrect Choices: B: Protein serum antigen is not a commonly known term in healthcare. There is no specific antigen called "protein serum antigen" used to determine protein levels. C: Pneumococcal strep antigen is a bacterial antigen that causes pneumonia, not related to PSA used in prostate cancer screening. D: Papanicolua-specific antigen is not a recognized term. The Papanicolaou test (Pap smear) is used for cervical cancer screening, not a specific antigen like PSA.
Question 3 of 9
In addition to antibiotics, which of the ff. recommendations can the nurse make to increase comfort in a patient experiencing sinusitis? Choose all answers that are correct. i. Coughing and deep breathing iv. Room humidifier ii. Sinus irrigation v. Percussion and postural drainage iii. Hot moist packs vi. Semi-fowler’s position
Correct Answer: D
Rationale: The correct answer is D: 2, 4, 5, and 6. 1. Room humidifier (choice 2) helps to keep the air moist, which can ease sinus pressure and discomfort. 2. Hot moist packs (choice 4) can provide relief by reducing congestion and promoting sinus drainage. 3. Percussion and postural drainage (choice 5) can help loosen mucus and improve drainage. 4. Semi-fowler's position (choice 6) can also aid in drainage and reduce sinus pressure. Choices A, B, and C are incorrect because they do not include all the recommended interventions that can help increase comfort in a patient with sinusitis. Each of the incorrect choices is missing at least one crucial recommendation that is beneficial for managing sinusitis symptoms.
Question 4 of 9
Which of the ff is the most severe complication among clients with allergies, regardless of type?
Correct Answer: B
Rationale: The correct answer is B, anaphylactic shock and angioedema, as it is the most severe complication of allergies and can be life-threatening. Anaphylactic shock can lead to airway constriction, severe drop in blood pressure, and organ failure. Angioedema can cause swelling of the face, lips, and throat, leading to difficulty breathing. Bronchitis (A) is a respiratory condition that can occur due to allergies but is not typically life-threatening. Cardiac arrest (C) is a serious complication but not directly related to allergies. Asthma and nasal polyps (D) are common allergic conditions but are not as immediately life-threatening as anaphylactic shock.
Question 5 of 9
During a breast examination, which finding most strongly suggests that the client has breast cancer?
Correct Answer: B
Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is a classic sign of breast cancer. This finding is concerning as it indicates an abnormal growth that has invaded surrounding tissues. Dimpling occurs due to fibrotic changes pulling on the skin. Choices A, C, and D are incorrect. A slight asymmetry of the breasts is common and not necessarily indicative of cancer. Bloody discharge from the nipple can be a sign of other conditions like intraductal papilloma. Multiple firm, round, freely movable masses that change with the menstrual cycle are likely benign fibrocystic changes.
Question 6 of 9
What is the purpose of pursed lip breathing?
Correct Answer: A
Rationale: The correct answer is A because pursed lip breathing helps to slow down and control the exhalation process, allowing the individual to exhale a smaller volume of air with more force. This helps to prevent air trapping in the lungs, improve oxygen exchange, and reduce shortness of breath. B: Incorrect - Pursed lip breathing does not increase expiration but rather controls it. C: Incorrect - While pursed lip breathing can promote deep breathing and better oxygen exchange, its primary purpose is to regulate exhalation volume. D: Incorrect - Pursed lip breathing does not specifically target the upper thorax but rather facilitates a more efficient breathing pattern by reducing air trapping in the lungs.
Question 7 of 9
Inhalation of carbogen for short period is recommended:
Correct Answer: D
Rationale: The correct answer is D. Carbogen is a gas mixture of carbon dioxide and oxygen. Inhaling carbogen can stimulate respiration due to increased oxygen levels and carbon dioxide acting as a respiratory stimulant. It can also dilate blood vessels, enhancing oxygen delivery to tissues. Additionally, carbogen can help dislodge blood clots by improving blood flow and oxygenation. Therefore, all the choices (A, B, and C) are correct as inhaling carbogen can have multiple beneficial effects on respiration, blood vessels, and blood clot dislodging.
Question 8 of 9
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 focus the interview on the patient's needs. This step helps in gathering important information and establishing rapport. Introductions are usually done at the beginning of the interview, so it is not the next step. Explaining that the interview will be over in a few minutes can create anxiety and hinder open communication. Telling the patient about administering medications in 1 hour is not relevant at this point in the interview.
Question 9 of 9
The nurse is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?
Correct Answer: B
Rationale: The correct answer is B: 7 to 14 days. Marrow suppression from floxuridine typically occurs 1-2 weeks after administration due to its effects on rapidly dividing cells in the bone marrow. This is known as the nadir period. Choices A, C, and D are incorrect because 24 hours is too soon for noticeable effects, 2 to 4 days is too short for the nadir period, and 21 to 28 days is too long for the onset of marrow suppression. The correct choice aligns with the expected timeframe for floxuridine's impact on bone marrow function.