ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 5
Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects would you anticipate from too rapid infusion rate?
Correct Answer: D
Rationale: Rationale: 1. Rapid infusion of hyperalimentation solutions can lead to circulatory overload due to increased fluid volume in the circulatory system. 2. Circulatory overload can result in symptoms such as hypertension, tachycardia, and edema. 3. Hypoglycemia can occur as a result of excess insulin release due to the sudden increase in glucose from the hyperalimentation solution. Summary: A. Cellular dehydration and potassium: Incorrect. Rapid infusion would lead to fluid overload, not dehydration. B. Hypoglycemia and hypovolemia: Incorrect. Hypovolemia is unlikely with rapid infusion, and hypoglycemia is a possible side effect. C. Potassium excess and CHF: Incorrect. Rapid infusion may cause circulatory overload, not CHF, and potassium excess is not a common side effect. D. Circulatory overload and hypoglycemia: Correct. These are the most likely side effects of rapid
Question 2 of 5
Then the drug is stopped. When should treatment resume?
Correct Answer: A
Rationale: The correct answer is A: When the WBC falls to 5,000mm3. This is because a low WBC count indicates potential bone marrow suppression from the drug. Resuming treatment at this point ensures the bone marrow has recovered enough to handle the drug's effects. Summary: - Choice B: Hair regrowth is not a reliable indicator of bone marrow recovery. - Choice C: A high WBC count suggests potential toxicity, not readiness for treatment. - Choice D: Anemia is a late sign of bone marrow suppression, not an appropriate indicator to resume treatment.
Question 3 of 5
The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on potential causes of their fatigue, leading to a more in-depth exploration of the issue. Option A focuses on stress, not necessarily fatigue. Option C is too specific and may not uncover underlying causes. Option D assumes sleep duration is the only factor contributing to fatigue.
Question 4 of 5
The nurse observes the temperature record of a client and relates the fever to the brain infection the client currently has. The nurse knows that a high temperature may lead to an increased cerebral irritation. Which of the ff measures can help the nurse control the clients body temperature? Choose all that apply
Correct Answer: A
Rationale: The correct answer is A: Providing tepid sponge bath. This measure helps lower body temperature through evaporation of water from the skin. It is effective in managing fever without causing shivering or discomfort. Ice packs (B) can lead to vasoconstriction and shivering, raising body temperature. Antipyretics (C) are drugs that can reduce fever but may not address the underlying cause. Keeping the room warm (D) can exacerbate fever by hindering heat dissipation.
Question 5 of 5
During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived?
Correct Answer: C
Rationale: During outcome identification and planning, outcomes are derived from the problem statement of the nursing diagnoses. This is because the problem statement clearly defines the patient's health issue or condition that needs to be addressed, thus guiding the development of specific, measurable, and achievable outcomes. The defining characteristics (choice A) describe the signs and symptoms of the health problem but do not directly lead to outcome identification. The related factors (choice B) represent the potential causes or contributing factors to the health problem and are not used to derive outcomes. The database (choice D) consists of the patient's health history, assessment data, and laboratory findings, which are essential for diagnosing but do not directly determine outcomes. Therefore, the correct answer is C as it directly informs the outcomes to be achieved.