ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 5
As part of primary cancer prevention program, an oncology nurse answers questions from the public at health fair. When someone asks about the laryngeal cancer, the nurse should explain that:
Correct Answer: A
Rationale: The correct answer is A: Laryngeal cancer is one of the most preventable types of cancer. This is because the primary risk factors for laryngeal cancer are largely related to lifestyle choices such as smoking, excessive alcohol consumption, and exposure to certain occupational hazards. By avoiding these risk factors, individuals can significantly reduce their chances of developing laryngeal cancer. Choices B, C, and D are incorrect: B: Inhaling polluted air isn’t a risk factor for laryngeal cancer - This is incorrect as exposure to polluted air can contribute to the development of laryngeal cancer. C: Laryngeal cancer occurs primarily in women - This is incorrect as laryngeal cancer occurs more frequently in men than in women. D: Adenocarcinoma accounts for most cases of laryngeal cancer - This is incorrect as squamous cell carcinoma is the most common type of laryngeal cancer, not adenocarcin
Question 2 of 5
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
Correct Answer: C
Rationale: Step 1: Safety First - The nurse's priority is patient safety. Without vital signs, medication administration can be unsafe. Step 2: Accountability - The nurse must ensure accurate and timely vital signs recording before making clinical decisions. Step 3: Delegation - Asking the NAP to record vital signs aligns with their role and helps maintain a reliable record. Step 4: Proactive Approach - By having the NAP record vital signs, the nurse can make informed decisions based on accurate data. Summary: A: Incorrect - Proceeding with medications without vital signs can risk patient safety. B: Incorrect - Waiting to review vital signs later can delay necessary interventions. D: Incorrect - Omitting vital signs is negligent and compromises patient care.
Question 3 of 5
Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?
Correct Answer: C
Rationale: The correct answer is C: Position lower extremities below level of heart. This intervention helps improve blood flow and perfusion to the lower extremities by utilizing gravity to assist in venous return. This is crucial for clients at risk for ineffective tissue perfusion post-cardiac surgery. A: Restricting fluid intake may lead to dehydration, which can worsen tissue perfusion. B: Ensuring the client avoids prolonged sitting is important for preventing blood clots, but it does not directly address tissue perfusion. D: Instructing the client to avoid leg exercises may hinder circulation and exacerbate issues related to tissue perfusion.
Question 4 of 5
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
Correct Answer: C
Rationale: The correct answer is C: Turn frequently every 2 hours. This helps redistribute pressure, preventing constant pressure on one area and reducing the risk of developing pressure ulcers. Turning every 2 hours promotes circulation and relieves pressure points. A: Massaging reddened areas can worsen the condition by increasing friction and pressure. B: While a special water mattress can help in preventing pressure ulcers, turning frequently is more effective. D: Keeping the skin clean and dry is important for overall skin health but may not directly prevent pressure ulcers.
Question 5 of 5
What is the primary purpose of validation as a part of assessment?
Correct Answer: D
Rationale: The primary purpose of validation in assessment is to ensure that the data collected is accurate and reliable to plan appropriate nursing care. Validation helps confirm the accuracy of data, identify inconsistencies, and ensure that the information gathered is trustworthy. By verifying the data, nurses can make informed decisions and tailor individualized care plans to meet the patient's needs effectively. Choices A, B, and C are incorrect because they do not directly relate to the purpose of validation in assessment. Choice A focuses on the identification of data, not the purpose of validation. Choice B and C pertain to communication and relationships, which are important but not the primary purpose of validation in the assessment process.
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