ATI RN
Nursing Process Test Bank Questions
Question 1 of 9
At the present time, the best treatment for cancer is complete __________ before metastasis occurs:
Correct Answer: C
Rationale: The correct answer is C: Surgical removal. Surgical removal of the cancerous tumor is the best treatment before metastasis because it physically removes the cancer cells. Chemotherapy and radiation are used to treat cancer after it has spread, not as the primary treatment. Choice D is incorrect because not all types of cancer can be effectively treated with all three options.
Question 2 of 9
A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?
Correct Answer: B
Rationale: The correct answer is B: Ask her to demonstrate her ability to ambulate. This response is best because it allows the nurse to assess the patient's actual ability to walk safely to the bathroom. By observing her, the nurse can ensure her safety and prevent potential falls. This approach also respects the patient's autonomy while prioritizing her safety. Incorrect responses: A: Allowing her to ambulate unassisted solely for positive self-esteem overlooks the importance of assessing her actual capability and ensuring safety. C: Explaining that assistance will always be available may not address the immediate need for assessment and safety. D: Asking another staff member to assist without assessing the patient's ability herself does not allow the nurse to directly evaluate the patient's safety and independence.
Question 3 of 9
A 45-year-old patient has a long- standing history of allergies to pollen. Which of the following actions indicates that the patient does not understand how to control this disease?
Correct Answer: C
Rationale: The correct answer is C. Driving in the car with the windows open exposes the patient to pollen, worsening allergies. Staying indoors on dry, windy days (A) reduces exposure. Refusing to walk outside in spring (B) also minimizes exposure. Working in the garden on sunny days (D) increases pollen exposure. Therefore, choice C is the only action that goes against controlling pollen allergies.
Question 4 of 9
Which of the ff should the nurse include in the teaching plan of a client with acute bronchitis?
Correct Answer: B
Rationale: The correct answer is B: Washing the hands frequently. This is important for preventing the spread of infection, which is crucial in acute bronchitis. By washing hands frequently, the client can reduce the risk of transmitting the infection to others and prevent reinfection. A: Not coughing frequently - While managing cough is important, it is not the most crucial aspect in the teaching plan for acute bronchitis. C: Consuming adequate calories - While nutrition is important for overall health, it is not specifically related to the management of acute bronchitis. D: Encouraging a semi-Fowler’s position - While this position can help with breathing, it is not the most important aspect in the teaching plan for acute bronchitis.
Question 5 of 9
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: providing for frequent rest periods. This intervention is essential for a client with radiation-induced thrombocytopenia to prevent further platelet depletion and reduce the risk of bleeding episodes. Rest periods help conserve energy and minimize physical exertion, which can trigger bleeding in thrombocytopenic clients. Rationale: 1. Administering aspirin (choice A) is contraindicated in thrombocytopenia as it can further decrease platelet count and increase the risk of bleeding. 2. Inspecting the skin for petechiae (choice B) is important but not as crucial as providing rest periods in managing thrombocytopenia. 3. Placing the client in strict isolation (choice D) is not necessary for radiation-induced thrombocytopenia unless there are other specific infectious concerns. In summary, providing frequent rest periods is the most appropriate intervention to manage radiation-induced thrombocytopenia, promoting patient
Question 6 of 9
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself?
Correct Answer: D
Rationale: The correct answer is D: Sitting at a 45-degree angle to the bed. This position allows the nurse to have a clear view of the client and maintain good communication. Sitting at a 45-degree angle enables the nurse to observe the client's facial expressions, body language, and interact effectively. Standing at the end of the bed (A) limits the nurse's view and communication. Standing at the side of the bed (B) may obstruct the nurse-client interaction. Sitting at least six feet away (C) creates unnecessary distance and hinders effective communication.
Question 7 of 9
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
Correct Answer: B
Rationale: The correct answer is B: The waiting area with the television turned off. This choice eliminates potential distractions, allowing the patient with a hearing deficit to focus on the interview. Noise from the television can interfere with communication. Other choices are incorrect because: A) The closed door may block out external noise, but the patient's room could still have distractions. C) Administering pain medication can affect the patient's alertness and ability to communicate effectively. D) The waiting room with occupational therapy activities can be noisy and distracting. Conducting the interview in a quiet waiting area ensures optimal communication and understanding.
Question 8 of 9
The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:
Correct Answer: B
Rationale: The correct answer is B: "Good oral hygiene is needed, including brushing and flossing." This is because phenytoin (Dilantin) can cause gingival hyperplasia, a side effect that leads to overgrowth of gum tissue. Good oral hygiene practices, such as regular brushing and flossing, can help prevent or minimize this side effect. Choice A is incorrect because alcohol is contraindicated while taking phenytoin as it can increase the risk of side effects and decrease the effectiveness of the medication. Choice C is incorrect because medication doses should never be self-adjusted without consulting a healthcare provider, as this can lead to ineffective treatment or potential harm. Choice D is incorrect because the timing of the morning dose in relation to drawing a serum drug level is not relevant to the client's understanding of medication instructions and does not address the specific side effect of gingival hyperplasia associated with phenytoin.
Question 9 of 9
A client seeks care for hopeless that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question.
Correct Answer: B
Rationale: The correct answer is B: “Have you strained your voice recently?” This question is relevant to the client's symptom of hopeless, as vocal strain can contribute to this issue. Asking about voice strain helps to identify a potential cause and guides further assessment and intervention. Choice A is not directly related to the client's primary concern and does not address the underlying cause of hopeless. Choice C is unrelated to the client's symptom and does not provide information that is pertinent to addressing the issue at hand. Choice D is also unrelated to the client's symptom of hopeless and does not address potential contributing factors.