ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 9
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 9
Which is the most reliable method for monitoring fluid balance?
Correct Answer: A
Rationale: The correct answer is A: Daily intake and output. Monitoring fluid balance involves tracking the amount of fluids taken in and expelled from the body. Intake includes oral, IV, and tube feedings, while output includes urine, vomitus, diarrhea, and any other fluid losses. Daily intake and output provide a comprehensive view of a patient's fluid status, helping identify trends and potential issues. Vital signs (B) provide general information but not specific to fluid balance. Daily weight (C) can fluctuate due to various factors, not just fluid status. Skin turgor (D) is a late sign of dehydration and not as reliable as intake and output monitoring.
Question 3 of 9
A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
Correct Answer: D
Rationale: The correct answer is D, as exercise and a weight reduction diet are essential components in managing type 2 diabetes. Exercise helps lower blood glucose levels and improves insulin sensitivity. Weight reduction reduces insulin resistance. Choice A is incorrect because maintaining blood glucose levels between 180-200mg/dl is too high and can lead to complications. Choice B is incorrect as complete smoking cessation is crucial for overall health and diabetes management. Choice C is incorrect because eye examinations should be done annually, not every 2 years, to monitor for diabetic retinopathy. In summary, choice D is the best option as it directly addresses the management of type 2 diabetes.
Question 4 of 9
Blood cells are formed in the:
Correct Answer: C
Rationale: The correct answer is C: Bone marrow. Blood cells are primarily formed in the bone marrow through a process called hematopoiesis. The bone marrow contains stem cells that differentiate into various types of blood cells, including red blood cells, white blood cells, and platelets. Arterioles are small blood vessels that carry blood away from the heart, not involved in blood cell formation. Lymphoid tissue plays a role in immune function but not in blood cell production. Muscle tissue is primarily responsible for movement and does not have a role in blood cell formation. Therefore, the bone marrow is the correct answer as it is the main site of blood cell production in the body.
Question 5 of 9
Why should the nurse monitor angiotensin converting enzyme inhibitors cautiously in clients with renal or hepatic impairment and in older adults?
Correct Answer: B
Rationale: The correct answer is B: A sudden drop in BP may occur during the first 1-3 hours after the initial dose. Angiotensin converting enzyme inhibitors can cause vasodilation, leading to a reduction in blood pressure. In clients with renal or hepatic impairment and in older adults, these medications may not be cleared from the body as efficiently, increasing the risk of hypotension. Monitoring is crucial to prevent complications. Incorrect choices: A: A sudden raise in BP is unlikely with angiotensin converting enzyme inhibitors. C: Angiotensin converting enzyme inhibitors do not affect body temperature. D: Angiotensin converting enzyme inhibitors typically do not cause a sudden rise in pulse rate. In summary, monitoring for a potential drop in blood pressure is essential in vulnerable populations when using angiotensin converting enzyme inhibitors.
Question 6 of 9
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for this patient is acute pain (Choice C). This is because the patient's right femur fracture would likely cause significant pain and discomfort, which is a priority to address for optimal recovery and comfort. Managing pain effectively is crucial in promoting healing and preventing complications. Posttrauma syndrome (Choice A) is not as immediate a concern in this scenario. While constipation (Choice B) and anxiety (Choice D) are important considerations, addressing acute pain takes precedence in the initial plan of care to ensure the patient's comfort and well-being.
Question 7 of 9
A patient with a new diagnosis of lung cancer decides to have radiation therapy. Which of the ff. expectations of this treatment is most appropriate?
Correct Answer: C
Rationale: The correct answer is C: Increased comfort. Radiation therapy for lung cancer aims to alleviate symptoms, reduce pain, and improve quality of life. It is not typically used as a curative treatment like surgery or chemotherapy (A). It does not prevent the need for oxygen (B), as lung cancer can still affect lung function. While radiation therapy may help control the growth of cancer cells, it is not always effective in preventing cancer spread (D). Therefore, the most appropriate expectation of radiation therapy for lung cancer is increased comfort for the patient.
Question 8 of 9
The following would be a symptom the nurse would expect to find during assessment of a patient with macular degeneration, EXCEPT:
Correct Answer: D
Rationale: The correct answer is D: Loss of peripheral vision. Macular degeneration affects the central vision, specifically the macula, which is responsible for central vision and sharp detail. Loss of peripheral vision is not a typical symptom of macular degeneration. The macula is located in the center of the retina, so symptoms would relate to central vision impairments such as decreased ability to distinguish colors, loss of central vision, and loss of near vision. Peripheral vision is not primarily affected by macular degeneration, hence it is not an expected symptom.
Question 9 of 9
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.