ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 9
At health fair, an oncology nurse answers questions about risk factors for various types of cancer. One person with a family history of colon cancer asks the nurse to identify risk factors for this type of cancer. The nurse should identify:
Correct Answer: B
Rationale: The correct answer is B: Obesity. Obesity is a known risk factor for colon cancer as excess body fat, especially around the waist, can lead to inflammation and insulin resistance, increasing the likelihood of cancerous cell growth in the colon. Smoking (choice A) is more strongly associated with lung and other types of cancer, not specifically colon cancer. Heavy alcohol consumption (choice C) is linked to other types of cancer, such as liver and esophageal cancer, but not as strongly to colon cancer. Saccharin consumption (choice D) has not been definitively linked to an increased risk of colon cancer.
Question 2 of 9
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
Correct Answer: D
Rationale: The correct answer is D: Immediately stop the transfusion, infuse normal saline solution, notify the blood bank. Rationale: 1. Stop the transfusion immediately to prevent further complications from the hemolytic reaction. 2. Infuse normal saline solution to maintain adequate hydration and support kidney function. 3. Notify the blood bank to report the adverse reaction and to return the blood products for further investigation and testing. Summary of other choices: A: Incorrect because infusing dextrose 5% in water (D5W) is not indicated for treating a hemolytic reaction. Calling the physician is important, but stopping the transfusion and notifying the blood bank are more critical. B: Incorrect because slowing the transfusion may not be sufficient to manage the acute hemolytic reaction effectively. C: Incorrect because administering antihistamines is not the appropriate treatment for a hemolytic reaction. Stopping the transfusion and notifying the blood bank are more urgent actions.
Question 3 of 9
A patient is admitted to a medical unit with a diagnosis of heart failure. The patient reports that she has had increasing fatigue during the past 2 weeks. Which of the following is the most likely cause of this fatigue?
Correct Answer: B
Rationale: The correct answer is B: Decreased cardiac output. Fatigue in heart failure is primarily due to decreased cardiac output, leading to reduced oxygen and nutrient delivery to tissues, causing fatigue. Dyspnea (A) is shortness of breath, not fatigue. Dry cough (C) is more associated with conditions like pulmonary issues, not fatigue. Orthopnea (D) is difficulty breathing while lying down, not specifically related to fatigue. Hence, decreased cardiac output is the most likely cause of fatigue in this patient.
Question 4 of 9
For a client with sickle cell anemia, how does the nurse assess for jaundice?
Correct Answer: C
Rationale: The correct answer is C because jaundice is a common manifestation of sickle cell anemia due to the breakdown of red blood cells. The nurse should inspect the skin and sclera for the characteristic yellow discoloration indicating jaundice. This assessment is specific to identifying jaundice, which is directly related to the disease process. Choice A is incorrect as it relates to assessing neurological function, not jaundice. Choice B is incorrect as joint swelling is not a typical sign of jaundice in sickle cell anemia. Choice D is incorrect as a urine specimen is not used to assess jaundice; skin and sclera inspection are more appropriate.
Question 5 of 9
A client is brought to the emergency department unconscious after a fall. What is the primary source of information in this case?
Correct Answer: A
Rationale: The correct answer is A: Client's spouse. In the case of an unconscious client, the spouse is the primary source of information about the client's medical history, medications, allergies, and recent events. This information is crucial for providing appropriate care. Medical records may not be immediately accessible. Diagnostic tests provide limited historical information. Nursing assessment relies on the client's condition, which may not provide comprehensive information.
Question 6 of 9
At health fair, an oncology nurse answers questions about risk factors for various types of cancer. One person with a family history of colon cancer asks the nurse to identify risk factors for this type of cancer. The nurse should identify:
Correct Answer: B
Rationale: The correct answer is B: Obesity. Obesity is a known risk factor for colon cancer as excess body fat, especially around the waist, can lead to inflammation and insulin resistance, increasing the likelihood of cancerous cell growth in the colon. Smoking (choice A) is more strongly associated with lung and other types of cancer, not specifically colon cancer. Heavy alcohol consumption (choice C) is linked to other types of cancer, such as liver and esophageal cancer, but not as strongly to colon cancer. Saccharin consumption (choice D) has not been definitively linked to an increased risk of colon cancer.
Question 7 of 9
The nurse is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse plan to use to dilute this medication?
Correct Answer: C
Rationale: The correct answer is C: Normal saline solution. Phenytoin is incompatible with dextrose solutions, so options A and D are incorrect. Lactated Ringer's solution contains calcium, which can interact with phenytoin, leading to precipitation. Therefore, option B is also incorrect. Normal saline is the most compatible diluent for phenytoin, maintaining the drug's stability and effectiveness. It is essential to use the appropriate diluent to prevent adverse reactions or drug interactions.
Question 8 of 9
A surgical intervention that can cause substantial remission of myasthenia gravis is:
Correct Answer: B
Rationale: The correct answer is B: Thymectomy. The thymus gland is often found to be abnormal in individuals with myasthenia gravis, and removing it through thymectomy can lead to substantial remission of symptoms. This is because the thymus plays a role in the development of the immune system and may be producing antibodies that attack neuromuscular junctions in myasthenia gravis. Choice A, esophagostomy, is a surgical procedure to create an opening in the esophagus for feeding and has no direct impact on myasthenia gravis. Choice C, myomectomy, is the removal of uterine fibroids and is unrelated to myasthenia gravis. Choice D, spleenectomy, is the removal of the spleen and is not a treatment for myasthenia gravis as the spleen is not implicated in the disease process.
Question 9 of 9
A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;
Correct Answer: B
Rationale: To calculate the drip rate, we first need to find the total volume of IV fluid to be administered, which is 1500 ml + 1250 ml = 2750 ml. Then, we multiply the total volume by the drop factor (2750 ml * 15 gtt/ml = 41250 gtt). Finally, we divide the total number of drops by the time in minutes (24 hours * 60 min = 1440 min) to get the drip rate: 41250 gtt / 1440 min = 28.47 gtt/min, which rounds up to 29 gtt/min. Therefore, choice B is correct. Choices A, C, and D are incorrect because they do not reflect the accurate calculation based on the given parameters.