ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 9
Compartment syndrome is a potential complication of elbow fractures that decreases circulation to local neuromuscular structures. The nurse monitors circulation on a casted elbow because irreversible damage can develop if compartment syndrome lasts for more than:
Correct Answer: D
Rationale: The correct answer is D: 24 hours. Compartment syndrome occurs when pressure within a closed muscle compartment increases, leading to decreased circulation and potential tissue damage. Monitoring is crucial as irreversible damage can occur if left untreated. The 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, pressure) are key indicators. Waiting for 48 hours (choice A) or 12 hours (choice C) is too long and can result in severe consequences. 2 hours (choice B) is too short a timeframe to assess for irreversible damage development, making 24 hours (choice D) the most appropriate timeframe for monitoring and intervention.
Question 2 of 9
Which of the following client outcomes best describes the parameters for achieving the outcome?
Correct Answer: B
Rationale: The correct answer is B because it provides specific, measurable, achievable, relevant, and time-bound (SMART) parameters for achieving the outcome. It outlines the calorie intake, meal frequency, and start date, which allows for clear monitoring and evaluation of progress. Choice A is too vague and lacks specificity. Choice C focuses on wound care, not dietary goals. Choice D lacks specificity and a timeframe, making it difficult to measure success. In conclusion, choice B is the best option as it aligns with effective goal-setting principles.
Question 3 of 9
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
Correct Answer: D
Rationale: The correct answer is D: “Remain supine for the time specified by the physician.” After a subarachnoid block, the client must remain lying down to prevent complications like spinal headaches due to cerebrospinal fluid leakage. This position helps maintain adequate spinal fluid pressure. Choice A is incorrect as fluid intake is important postoperatively. Choice B is not relevant to a subarachnoid block. Choice C is important but not the most crucial instruction compared to maintaining the supine position.
Question 4 of 9
The client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?
Correct Answer: B
Rationale: The correct answer is B: Direct bilirubin level of 2 mg/dl. Acetaminophen toxicity can lead to liver damage, causing an increase in bilirubin levels. Direct bilirubin specifically indicates liver function. A: Sodium level is not related to acetaminophen toxicity. C: Prothrombin time is a measure of blood clotting, not indicative of acetaminophen toxicity. D: Platelet count is not affected by acetaminophen toxicity.
Question 5 of 9
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
Correct Answer: A
Rationale: The correct answer is A: Platelet count, prothrombin time, and partial thromboplastin time. These parameters are essential in monitoring DIC because platelet count reflects the risk of bleeding, while prolonged prothrombin time and partial thromboplastin time indicate impaired clotting function, which is characteristic of DIC. Explanation for why other choices are incorrect: - Choice B: Blood glucose levels and WBC count are not specific indicators for DIC monitoring. - Choice C: Thrombin time, calcium levels, and potassium levels do not directly assess clotting abnormalities associated with DIC. - Choice D: While fibrinogen level is important in DIC, WBC count alone is not a specific indicator for monitoring DIC.
Question 6 of 9
A client who is scheduled for a parathyroidectomy is worried about having to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
Correct Answer: C
Rationale: The correct answer is C: Disturbed body image related to the incision scar. This nursing diagnosis is appropriate as the client's concern about wearing a scarf post-surgery indicates a potential disturbance in body image due to the visible scar. The nurse should address the client's emotional response and offer support to help cope with the change in appearance. A: Risk for impaired physical mobility due to surgery - This choice is not directly related to the client's worry about wearing a scarf and focuses more on physical limitations post-surgery. B: Ineffective denial related to poor coping mechanisms - This choice does not address the specific body image concern expressed by the client. D: Risk of injury related to surgical outcomes - This choice does not address the client's emotional response to the scar and focuses on physical safety risks instead.
Question 7 of 9
The nurse would expect which of the following would be included in the plan of care/
Correct Answer: D
Rationale: Step 1: Monitoring electrolytes is essential to assess for potential imbalances due to the use of sodium bicarbonate, which can lead to hypokalemia and hypocalcemia. Step 2: Hypokalemia and hypocalcemia can result in serious complications such as cardiac arrhythmias and muscle weakness. Step 3: By monitoring electrolytes, the nurse can detect imbalances early and intervene promptly to prevent adverse effects. Summary: A: Drinking excessive water can lead to electrolyte imbalances and is not directly related to the use of sodium bicarbonate. B: Administering NaHCO3 IV is not within the nurse's scope of practice and should be done based on physician's orders. C: Continuing sodium bicarbonate for nausea may not be appropriate without monitoring electrolytes to prevent potential imbalances.
Question 8 of 9
A patient is unable to control his bowels ff. a subarachnoid hemorrhage. Which intervention by the nurse can help reduce episodes of bowel incontinence?
Correct Answer: C
Rationale: The correct answer is C: Toilet the patient according to his pre-illness schedule, whether or not he feels the urge. This intervention helps establish a routine for bowel movements, which can aid in reducing episodes of bowel incontinence. By following the patient's pre-illness schedule, the nurse can help regulate bowel movements and prevent accidents. A: Asking the patient frequently if he has to have a bowel movement may not address the underlying issue of bowel incontinence. B: Placing incontinence pads on the patient's bed and chair is a reactive measure and does not address the root cause of the issue. D: Taking care not to embarrass the patient when incontinent episodes occur is important for emotional support but does not directly address reducing episodes of bowel incontinence.
Question 9 of 9
The following are warning signs of cancer. Which one is not?
Correct Answer: B
Rationale: The correct answer is B, weight gain, as it is not typically considered a warning sign of cancer. Changes in bladder and bowel habits (A), indigestion or difficulty in swallowing (C), and a nagging cough or hoarseness (D) are commonly associated with various types of cancer. Weight gain is more commonly linked to factors such as diet, exercise, and hormonal imbalances rather than cancer. It is important to be vigilant about the other warning signs and seek medical attention if any of those symptoms persist.