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
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 3 of 9
A nurse is documenting the progress of a client who has been recovering from a myocardial infarction. Which of the following would be most appropriate to include in the evaluation?
Correct Answer: B
Rationale: The correct answer is B because it directly reflects the client's progress in physical activity, a key indicator of recovery post-myocardial infarction. Walking 500 meters without chest pain shows improved cardiovascular function and exercise tolerance. Vital signs and lab results from admission (A) are important for initial assessment but not for ongoing evaluation. Physician notes (C) may provide insights but do not directly measure the client's progress. Medications prescribed (D) are important but do not reflect the client's specific improvement in physical activity.
Question 4 of 9
The clinical manifestations of Parkinson’s disease (bradykinesia rigidity and tremors) is directly related to a decreased level of:
Correct Answer: C
Rationale: The correct answer is C: Dopamine. Parkinson's disease is primarily caused by a deficiency of dopamine in the brain, leading to the characteristic symptoms of bradykinesia, rigidity, and tremors. Dopamine is a neurotransmitter involved in movement control. Acetylcholine (Choice A) is not directly related to Parkinson's disease, although its imbalance can contribute to other movement disorders. Serotonin (Choice B) and Phenylalanine (Choice D) are not primarily involved in the pathophysiology of Parkinson's disease.
Question 5 of 9
Which of the ff. nursing diagnoses is the focus of care for a patient with hypertension?
Correct Answer: D
Rationale: The correct answer is D: Deficient knowledge. This nursing diagnosis is appropriate because educating the patient about hypertension, its management, lifestyle modifications, and medication adherence is crucial in improving outcomes. Activity intolerance (A) and impaired physical mobility (B) are not typically primary focuses for hypertension but may be secondary concerns. Ineffective airway clearance (C) is unrelated to hypertension. Therefore, D is the most relevant option for addressing the patient's needs.
Question 6 of 9
A post-TURP patient experiences dribbling following removal of his catheter. Which action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Teach him to perform Kegel's exercises 10 to 20 times per hour. This is the appropriate action because Kegel's exercises help strengthen the pelvic floor muscles, which can improve urinary control and reduce dribbling post-TURP. Restricting fluid intake (A) is not necessary and may lead to dehydration. Reinserting the Foley catheter (C) is not recommended as it can increase the risk of infection. Reassuring the patient (D) without providing any intervention is not addressing the issue. Teaching Kegel's exercises is the most effective and non-invasive approach to manage post-TURP dribbling.
Question 7 of 9
Which of the following is an intraoperative outcome for a patient undergoing an inguinal hernia repair?
Correct Answer: C
Rationale: The correct answer is C: Maintains skin integrity. During inguinal hernia repair surgery, maintaining skin integrity is crucial to prevent infection and ensure proper wound healing. This outcome focuses on the physical aspect of the surgery and reflects the patient's skin condition postoperatively. Verbalizing fears (A) addresses emotional concerns, demonstrating leg exercises (B) is related to postoperative rehabilitation, and explaining deep breathing exercises (D) targets respiratory function, none of which directly assess the intraoperative outcome of skin integrity.
Question 8 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 9 of 9
When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?
Correct Answer: A
Rationale: The correct answer is A: A normal finding. The Darwin tubercle is a small, painless, bony nodule at the helix of the ear and is considered a normal anatomical variation. It is present in a significant portion of the population, regardless of age. It does not indicate any pathology or abnormality. Choices B, C, and D are incorrect because the presence of a Darwin tubercle is not indicative of any abnormality, and it is not limited to older adults.