Questions 9

ATI RN

ATI RN Test Bank

Nursing Process Final Exam Questions Questions

Question 1 of 5

JR is admitted to the medical-surgical unit because of a diagnosis of nephritic syndrome. What is the hallmark of this syndrome?

Correct Answer: C

Rationale: The hallmark of nephritic syndrome is edema due to proteinuria leading to hypoalbuminemia. Protein loss in urine causes decreased colloid osmotic pressure, leading to fluid leaking into tissues, causing edema. Osmotic diuresis (A) is unrelated to nephritic syndrome. Hypolipidemia (B) and hyperproteinemia (D) are not characteristic of nephritic syndrome.

Question 2 of 5

A patient visiting with family members in the waiting area tells the nurse “I don’t feel good, especially in the stomach.” What should the nurse do?

Correct Answer: B

Rationale: The correct answer is B: Ask the patient to return to the room, so the nurse can inspect the abdomen. Rationale: 1. Patient safety: By examining the patient's abdomen, the nurse can assess for any signs of distress or potential medical issues. 2. Patient-centered care: It is essential to prioritize the patient's well-being by addressing their concerns promptly and appropriately. 3. Professional responsibility: Nurses are trained to assess and evaluate patient symptoms to provide necessary care and support. Summary: A: Requesting the family to leave does not address the patient's symptoms and may disrupt the patient's support system. C: Asking about bowel movements and offering food may not be appropriate if the patient is experiencing stomach discomfort. D: Offering food without proper assessment may worsen the patient's condition and is not recommended before a proper evaluation.

Question 3 of 5

Wilma knew that James have an adequate respiratory condition if she notices that

Correct Answer: A

Rationale: The correct answer is A because a normal respiratory rate for an adult is typically between 12-20 breaths per minute. A respiratory rate of 18 falls within this range, indicating adequate respiratory function. Choice B is incorrect because an oxygen saturation of 91% is below the normal range of 95-100%, suggesting potential respiratory insufficiency. Choice C is incorrect as frank blood suction from the tube indicates a serious issue such as bleeding, not adequate respiratory condition. Choice D is also incorrect as the presence of a moderate amount of tracheobronchial secretions may indicate a respiratory infection or other respiratory issue, not necessarily adequate respiratory condition.

Question 4 of 5

Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?

Correct Answer: D

Rationale: The correct answer is D because using two pillows to raise the head can increase the risk of venous stasis and thrombosis in a client with polycythemia vera. This condition involves an increased production of red blood cells, leading to thicker blood and potential clot formation. Elevating the head too much can impede blood flow, exacerbating the risk of clotting. Choices A, B, and C are all appropriate statements indicating good self-care practices and physical activity, which are beneficial for clients with polycythemia vera to improve circulation and overall health.

Question 5 of 5

Which of the following nursing interventions is appropriate after a lumbar puncture?

Correct Answer: A

Rationale: The correct answer is A: Have the patient lie flat for 6 to 8 hours after a lumbar puncture to prevent complications like post-lumbar puncture headache. Lying flat helps maintain CSF pressure and reduce the risk of leakage. B: Keeping the patient from eating or drinking for 4 hours is not necessary after a lumbar puncture. C: Monitoring pedal pulses q4h is irrelevant to post-lumbar puncture care. D: Keeping the head of the bed elevated 30 degrees for 24 hours is not recommended after a lumbar puncture as it may increase the risk of complications.

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