ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 5
Arthur, a 66-year old client for pneumonia has a temperature ranging from 39° to 40° C with periods of diaphoresis. Which of the following interventions by Nurse Carlos would be a priority?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen therapy. This is the priority intervention because a high temperature and diaphoresis indicate potential respiratory distress. Oxygen therapy can help improve oxygenation and support respiratory function. Providing frequent linen changes (B) is important for hygiene but not the priority. Fluid intake (C) is essential but not as urgent as addressing respiratory distress. Maintaining complete bed rest (D) may be necessary but addressing oxygenation takes precedence in this case.
Question 2 of 5
A patient asks the nurse what is CYSTOCLYSIS? The best explanation would be:
Correct Answer: B
Rationale: Rationale: B is correct because cystoclisis is the process of maintaining patency of a foley catheter by irrigating it with a sterile solution. This prevents blockages and promotes proper drainage. A, C, and D are incorrect because cystoclisis is not related to increasing bladder atony, removing blood clots, or altering urine specific gravity.
Question 3 of 5
The staff nurse in a regional hospital is aware that a dose of parenteral ampicillin must be administered within how many hours after it has been mixed?
Correct Answer: B
Rationale: The correct answer is B (4 hours) because parenteral ampicillin should be administered within 1 hour of mixing. This is crucial to ensure efficacy and prevent bacterial growth in the solution. Choice A (1 hour) is incorrect because it does not allow enough time for administration after mixing. Choice C (2 hours) is also incorrect as it exceeds the recommended time limit. Choice D (8 hours) is incorrect as it exceeds the safe window for administration post-mixing, increasing the risk of bacterial contamination and reduced effectiveness. Thus, the optimal timeframe for administering parenteral ampicillin after mixing is within 4 hours to maintain its therapeutic benefits.
Question 4 of 5
The client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for:
Correct Answer: D
Rationale: The correct answer is D, decreased body temperature and cold intolerance, because these are classic signs of hypothyroidism due to decreased thyroid hormone levels. The body's metabolism slows down, leading to a lower core body temperature and reduced ability to tolerate cold. Exophthalmos and conjunctival redness (choice A) are associated with hyperthyroidism. Flushed, warm, moist skin (choice B) is indicative of hyperthyroidism as well, due to increased metabolic rate. A systolic murmur at the left sternal border (choice C) is not a common finding in hypothyroidism.
Question 5 of 5
The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
Correct Answer: D
Rationale: The correct answer is D: vasopressin (Pitressin). In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), which leads to excessive urination and thirst. Vasopressin is a synthetic form of ADH that helps regulate water balance by reducing urine output. Therefore, administering vasopressin would help manage the symptoms of diabetes insipidus. Insulin (A) is used for diabetes mellitus, not diabetes insipidus. Potassium chloride (B) is used to correct potassium imbalances, not specific to diabetes insipidus. Furosemide (Lasix) (C) is a diuretic that increases urine output, which would worsen the symptoms of diabetes insipidus.