ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 9
Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
Correct Answer: C
Rationale: Step 1: Mr. Franco's condition suggests he may need support and positioning. Step 2: Sandbags provide stability and trochanter rolls prevent hip rotation. Step 3: These help prevent pressure ulcers and maintain proper body alignment. Step 4: Hand bell and bed linen are not essential for Mr. Franco's immediate care. Step 5: Footboard and splint may not be relevant to his specific condition. Step 6: Suction machine and gloves are important but not as crucial as positioning aids for Mr. Franco. Summary: Choice C is correct as it directly addresses Mr. Franco's needs for support and positioning, while the other choices are less relevant or not as essential in this context.
Question 2 of 9
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Lymphangitis is an inflammation of lymphatic vessels. 2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection. 3. Nurse should notify the physician for further evaluation and treatment. 4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification. 5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification. 6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.
Question 3 of 9
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
Correct Answer: B
Rationale: The correct answer is B because Toni's behavior of minimizing her visual problems, focusing on future goals, seeking information about job opportunities, and expressing desire for more children reflects coping mechanisms used to deal with the exacerbation of her illness. This behavior suggests that she is trying to maintain a sense of normalcy and control in the face of her health challenges. A: Inappropriate euphoria is excessive happiness or excitement, which is not evident in Toni's behavior. C: Remission phase typically involves a decrease in symptoms, which is not reflected in Toni's situation. D: Realistic for her current level of physical functioning does not explain her behavior as coping mechanisms.
Question 4 of 9
A nurse evaluates a client’s response to a nursing intervention and determines that the expected outcome was not achieved. What is the nurse’s most appropriate action?
Correct Answer: D
Rationale: The correct answer is D: Reassess the client's condition. When an expected outcome is not achieved, the nurse must reassess the client's condition to identify the reasons for the lack of success. This step allows the nurse to gather more information, adjust the plan of care if necessary, and determine the most suitable course of action to help the client achieve the desired outcome. Choice A: Terminating the plan of care is premature without reassessing the client's condition and identifying potential barriers to success. Choice B: Modifying the plan of care may be necessary after reassessment but should not be the first step. Choice C: Reassigning care to another nurse does not address the underlying issues affecting the client's response to the intervention.
Question 5 of 9
Olympic gymnast Ms. Slovenski sufferd a great fall and suffered a great fall and fractured her femur. Approximately after 20 hours in the hospital she became dyspneic, tachypneic, and with scattered crackles in her lung fields. She is coughing up large amounts of thick, white sputum. The nurse correctly interprets this as:
Correct Answer: C
Rationale: The correct answer is C: fat embolism syndrome related to femur fracture. Fat embolism syndrome occurs when fat globules enter the bloodstream and travel to the lungs, causing respiratory distress. In this case, the patient's femur fracture likely led to fat embolism, explaining her dyspnea, tachypnea, crackles, and thick sputum. Choices A, B, and D do not align with the patient's presentation and history, making them incorrect. Choice A suggests smoke inhalation, which is not supported by the scenario. Choice B mentions pneumonia from bedrest, which is not a common complication of immobility. Choice D proposes hypovolemic shock from multiple trauma, which does not explain the respiratory symptoms and sputum production observed in the patient.
Question 6 of 9
A 23 y.o. woman is seen at an outpatient clinic for a routine Pap smear. When questioned, she states she is deciding whether to engage in sexual activity with a man she is just getting to know. She asks how she can tell if he has an STD. Which response by the nurse is best?
Correct Answer: D
Rationale: Step 1: The correct answer is D because it emphasizes the importance of medical examination and diagnostic testing to determine if the man has an STD. Step 2: Visual inspection (choice B) is not reliable as some STDs may not present with visible symptoms. Step 3: Relying solely on appearance and condom use (choices A and C) does not guarantee protection against all STDs. Step 4: Choice D is the best option as it advocates for seeking professional medical advice for accurate diagnosis and treatment.
Question 7 of 9
The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?
Correct Answer: D
Rationale: The correct answer is D because the absence of skin breakdown indicates that the turning schedule was effective in preventing pressure ulcers. Skin breakdown is a key indicator of pressure ulcer development, so its absence suggests that the patient's skin integrity was maintained. Choice A is incorrect because documentation alone does not guarantee successful prevention. Choice B is incorrect as redness on the heels can still indicate the early stages of pressure ulcers. Choice C is unrelated to skin integrity and pressure ulcer prevention.
Question 8 of 9
Mr. Reyes has a possible skull fracture. The nurse should:
Correct Answer: A
Rationale: The correct answer is A because signs of brain injury, such as altered level of consciousness, unequal pupil size, and clear fluid draining from the nose or ears, indicate a need for urgent medical attention. Choice B is incorrect because hemorrhaging from the oral cavity is not a common sign of a skull fracture. Choice C is incorrect as elevating the foot of the bed is not appropriate for a skull fracture but may be done for shock. Choice D is incorrect because decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.
Question 9 of 9
A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo- oopherectomy with tumor secretion, omentectomy, appendectomy, and lymphadenopathy. During the second postoperative day, which of the following assessment findings would raise concern in the nurse?
Correct Answer: D
Rationale: The correct answer is D: Shallow breathing and increasing lethargy. This finding could indicate a potential respiratory complication such as atelectasis or pneumonia, which are common postoperative complications. Shallow breathing can lead to inadequate oxygenation and ventilation, causing lethargy due to decreased oxygen delivery to tissues. It is crucial to assess and address respiratory issues promptly to prevent further complications. A: Abdominal pain is expected postoperatively and can be managed with pain medications. B: Serous drainage from the incision is a normal finding after surgery and indicates the wound is healing properly. C: Hypoactive bowel sounds are common after surgery due to decreased peristalsis and can be managed with interventions such as early ambulation and medications.