ATI RN
Nursing Process Exam Questions Questions
Question 1 of 5
For a patient who is being discharged on digoxin, the nurse should include which of the ff. in an explanation to the patient on the signs and symptoms of digoxin toxicity?
Correct Answer: B
Rationale: The correct answer is B: Halos around lights. Digoxin toxicity can cause visual disturbances like seeing halos around lights, which is a common symptom. This is due to its effect on the eyes. Poor appetite (choice A) is a common side effect but not specific to toxicity. Constipation (choice C) is not a typical sign of digoxin toxicity. Tachycardia (choice D) is more commonly associated with digoxin toxicity, but visual disturbances like halos around lights are more specific and should be explained to the patient.
Question 2 of 5
A 90 y.o. nursing home resident with stage 2 Alzheimer’s disease is found alone and crying in the dining room. She says she lost her mother and doesn’t know what to do. Which response by the nurse will help calm the resident?
Correct Answer: C
Rationale: The correct answer is C: “Are you feeling frightened? I’m here and I will help you.” This response acknowledges the resident’s feelings, offers reassurance, and provides support, focusing on the resident's emotional needs rather than the accuracy of her statements. It shows empathy and validation of her feelings, which can help calm the resident and build trust. Choice A is incorrect because it dismisses the resident's feelings and reality, which can lead to increased distress and confusion. Choice B is incorrect as it doesn't address the resident's emotional state or offer immediate support. Choice D is incorrect as it focuses on correcting the resident's perception rather than providing emotional support, which may lead to further distress.
Question 3 of 5
The nurse in the postoperative unit prepares to receive a client after a balloon angioplasty of the carotid artery. Which of the ff items of priority should the nurse keep at the bedside for such client?
Correct Answer: A
Rationale: Rationale: 1. A: Blood pressure apparatus is essential to monitor for any signs of bleeding or clot formation after carotid angioplasty. 2. B: IV infusion stand is important but not the priority for immediate postoperative monitoring. 3. C: Call bell is important for the client to call for assistance but not the priority for immediate postoperative care. 4. D: Endotracheal intubation is not necessary after a carotid angioplasty and is not a priority item for bedside care. Summary: Monitoring blood pressure is crucial for detecting complications post carotid angioplasty. IV stand, call bell, and endotracheal intubation are important but not the priority in this scenario.
Question 4 of 5
An adult is receiving total parenteral nutrition. The nurse knows which of the following assessments is essential?
Correct Answer: D
Rationale: The correct answer is D: Fluid and electrolyte monitoring. In total parenteral nutrition (TPN), monitoring fluid and electrolyte balance is crucial to prevent complications like dehydration, electrolyte imbalances, and overload. Regular assessment ensures the patient's stability and prevents potential adverse effects. Option A (Evaluation of the peripheral venous site) is important but not essential compared to maintaining fluid and electrolyte balance. Option B (Confirmation that the tube is in the stomach) is irrelevant for a patient receiving TPN as it bypasses the GI tract. Option C (Assessment of the GI tract, including bowel sounds) is not necessary as TPN is given intravenously, bypassing the GI tract altogether.
Question 5 of 5
An adult has a Hickman type central venous catheter and needs to have blood drawn from it. Which of the following should the nurse do first?
Correct Answer: C
Rationale: The correct answer is C because flushing the central venous catheter with a heparinized solution before blood withdrawal is essential to maintain catheter patency and prevent clot formation. This step ensures the catheter is clear of any blockages, allowing for accurate blood sampling. Choice A is incorrect because assembling supplies should come after preparing the catheter. Choice B is incorrect as discarding blood before flushing the catheter may lead to inaccurate test results. Choice D is incorrect as replacing the catheter cap without flushing may lead to clot formation and catheter malfunction.