ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
As the surgical incision is closed, who are the personnel in-charge in counting the needles, sponges, and instruments?
Correct Answer: C
Rationale: The correct answer is C - the circulating and scrub nurse first assistant. The circulating nurse is responsible for counting needles, sponges, and instruments during the closing of the surgical incision to ensure nothing is left inside the patient. The scrub nurse first assistant also plays a crucial role in this process by assisting in the counting and keeping track of the items used during the procedure. The other choices are incorrect because the surgeon and anesthesiologist (A) are not typically involved in counting items during the surgical closure, the surgeon and the registered (B) may not have the necessary training for accurate counting, and the anesthesiologist and anesthetist (D) are not directly involved in the surgical closing process.
Question 2 of 5
. During the first 24 hours after a client is diagnosed with Addisonian crisis, which of the following should the nurse perform frequently?
Correct Answer: D
Rationale: The correct answer is D, assess vital signs, as it is crucial to monitor the client's hemodynamic stability and response to treatment during the critical initial 24 hours of Addisonian crisis. Vital signs such as blood pressure, heart rate, and respiratory rate provide valuable information about the client's condition and response to therapy. Weighing the client (choice A) and testing urine for ketones (choice C) may be important but not as immediately critical as monitoring vital signs. Administering oral hydrocortisone (choice B) is essential for treatment but does not require frequent administration within the first 24 hours.
Question 3 of 5
A client with diabetes mellitus has a prescription for 5 U-100 regular insulin and 25 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?
Correct Answer: C
Rationale: The correct answer is C: Hypoglycemia. At 4:30 p.m., after taking the morning insulin, the client's blood sugar may have dropped too low, leading to symptoms like headache, sweating, tremor, pallor, and nervousness. Regular insulin and NPH insulin peak at different times, causing a potential mismatch in insulin action, leading to hypoglycemia. Hyperglycemia (A) would present with different symptoms like increased thirst and urination. Hyperuricemia (B) is an excess of uric acid in the blood and does not typically present with these symptoms. Hypochondria (D) is a psychological condition and not related to the client's physical symptoms.
Question 4 of 5
When caring for a client, whose being treated for hyperthyroidism, it’s important to:
Correct Answer: B
Rationale: The correct answer is B. Monitoring for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy is essential in managing hyperthyroidism. Restlessness can indicate increased metabolic rate, sweating can be due to excessive heat production, and weight loss can be a sign of overactive thyroid function. Providing extra blankets (Choice A) may worsen symptoms of heat intolerance. Balancing activity and rest (Choice C) is important, but not specific to hyperthyroidism. Encouraging activity to prevent constipation (Choice D) is not directly related to managing hyperthyroidism.
Question 5 of 5
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
Correct Answer: C
Rationale: The correct answer is C. Rolling Mr. Gabatan on his abdomen, placing a pad under his head, and covering him with any material available is the appropriate action. This position helps protect his airway and prevents potential complications from a possible spinal injury. It also allows for better assessment of his condition by healthcare professionals. Choice A is incorrect because leaving Mr. Gabatan on his back and instructing him to move can worsen any spinal injury he may have sustained. Choice B is incorrect because raising him to a sitting position can also exacerbate his condition. Choice D is incorrect because moving him without proper stabilization can lead to further injury.