ATI RN
Nursing Process Practice Questions Questions
Question 1 of 5
During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?
Correct Answer: D
Rationale: The correct answer is D: “You must avoid hyperextending your neck after surgery.” This is because hyperextending the neck can put excessive strain on the surgical site, leading to potential complications such as bleeding or injury to the incision. Keeping the neck in a neutral position helps promote healing and reduces the risk of complications. A: “The head of your bed must remain flat for 24 hours after surgery.” - Incorrect. Elevating the head of the bed can help reduce swelling and promote drainage after thyroidectomy. B: “You should avoid deep breathing and coughing after surgery.” - Incorrect. Deep breathing and coughing are important to prevent respiratory complications such as pneumonia. C: “You won’t be able to swallow for the first day or two.” - Incorrect. Swallowing may be difficult initially but should improve gradually after surgery.
Question 2 of 5
A 27-year old adult is admitted for treatment of Crohn’s disease. Which information is most significant when the nurse assesses nutritional health?
Correct Answer: A
Rationale: The correct answer is A: Anthropometric measurements. This includes height, weight, and body mass index, which are crucial indicators of the nutritional status of a patient with Crohn's disease. It helps assess malnutrition, muscle wasting, and overall nutritional health. Dry skin (B), bleeding gums (C), and facial rubor (D) are not direct indicators of nutritional health in a patient with Crohn's disease. Dry skin may indicate dehydration, bleeding gums may suggest poor oral hygiene or gum disease, and facial rubor may be a sign of inflammation but are not specific to nutritional status.
Question 3 of 5
Mr. Sison had an above the knee amputation (AKA). He is taught to use crutches while prosthesis is being adjusted. The nurse instruct the client to support her weight primarily on which areas?
Correct Answer: A
Rationale: The correct answer is A: axilla. When using crutches, weight should primarily be supported on the axilla to prevent nerve and blood vessel damage in the armpit area. Supporting weight on the upper arms (B) can lead to nerve compression and muscle strain. Supporting weight on the elbows (C) can cause nerve damage and discomfort. Supporting weight on the hands (D) can lead to hand and wrist pain and may not provide stable support. Therefore, the axilla is the most appropriate area to support weight while using crutches to ensure safety and comfort for the client.
Question 4 of 5
Mr. Mariano was on his way home from a party. Apparently, he got drunk and lost his balance and suffered a vehicular accident. Upon arrival at the hospital, the nurse noticed that his only injury is an open fracture of the left humerus. Which assessment finding by the nurse is critical?
Correct Answer: A
Rationale: The correct answer is A: status of client’s tetanus immunization. It is critical because an open fracture poses a risk of infection, and tetanus prophylaxis is necessary to prevent tetanus infection. Tetanus is caused by a bacterium commonly found in soil and can enter the body through open wounds. Assessing the client's tetanus immunization status helps determine the need for a tetanus booster to prevent potential complications. Incorrect choices: B: Current blood alcohol level - While relevant to the situation, the priority in this case is preventing infection from the open fracture. C: Support systems available at home to assist with care - Important for discharge planning but not the immediate priority. D: Last time client voided - Not critical in this scenario compared to preventing infection from the open fracture.
Question 5 of 5
In the operating room, personnel should be responsible for ensuring cleanliness, proper temperature, humidity, and lighting. Who carries those responsibilities?
Correct Answer: A
Rationale: The correct answer is A: circulating nurse. The circulating nurse is responsible for maintaining cleanliness, ensuring proper temperature, humidity, and lighting in the operating room. They coordinate activities, manage supplies, and ensure a safe environment for the surgical team. The scrub nurse assists the surgeon with instruments and supplies, not environmental conditions. The surgeon's main focus is on performing the surgery, not environmental management. The anesthesiologist is responsible for administering anesthesia and monitoring the patient's vital signs, not the operating room environment.