ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 5
Mr. Kawasaki, a 23-year old industrial worker, was burned severely in an industrial accident. He has second degree burns on his right leg and arm, and on his left leg. He has third degree burns on his left arm. The triage nurse, using the rule of nines, estimates the extent of burn as:
Correct Answer: C
Rationale: The rule of nines is a method used to estimate the extent of burns on a patient's body. According to this rule, each major body part is assigned a percentage value that represents the total body surface area (TBSA). In this case, Mr. Kawasaki has second-degree burns on his right leg and arm (9% each) and left leg (9%) and third-degree burns on his left arm (9%). Adding these percentages together, we get a total of 36%, which corresponds to the extent of burn on Mr. Kawasaki's body. Choice A (18%) is incorrect because it only considers one arm and one leg, neglecting the other affected areas. Choice B (45%) is incorrect as it overestimates the extent of burns by including additional body parts not affected. Choice D (54%) is also incorrect as it includes more body parts than those actually burned. Therefore, the correct answer is C (36%) as it accurately reflects the distribution of burns based
Question 2 of 5
A client tells the nurse that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:
Correct Answer: D
Rationale: The correct answer is D: Glycosylated hemoglobin level. This test provides an average blood glucose level over the past 2-3 months, reflecting long-term glycemic control. It is a more reliable indicator compared to other options. A: Urine glucose level only shows current glucose levels and is not a reliable indicator of long-term control. B: Serum fructosamine level reflects blood glucose control over the past 2-3 weeks, not the 3-month period the client has been making efforts. C: Fasting blood glucose level gives a snapshot of the current glucose level, not long-term control like glycosylated hemoglobin does.
Question 3 of 5
Which white blood cells are involved in releasing histamine during an allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Basophils. Basophils are a type of white blood cell that release histamine during allergic reactions. They contain granules filled with histamine, which is released when they encounter an allergen. Monocytes, eosinophils, and neutrophils do not release histamine during allergic reactions. Monocytes are involved in immune response and inflammation, eosinophils are responsible for combating parasitic infections, and neutrophils are primarily involved in fighting bacterial infections.
Question 4 of 5
Which of the following nursing activities is an example of evaluation?
Correct Answer: A
Rationale: The correct answer is A because checking a client's blood pressure after administering medication assesses the effectiveness of the intervention. Evaluation involves determining if the desired outcomes were achieved. Administering oxygen therapy (B) is an implementation task. Developing a plan of care (C) is part of the assessment and planning phase. Teaching about dietary options (D) is part of the implementation phase. In conclusion, only option A involves assessing the outcome of an intervention, making it the correct choice for evaluation.
Question 5 of 5
Which of the following types of hearing loss does the nurse understand is most improved with the use of a hearing aid?
Correct Answer: C
Rationale: The correct answer is C: Sensorineural hearing loss. Hearing aids are most effective for sensorineural hearing loss as they amplify sound signals to compensate for damage to the inner ear hair cells or auditory nerve. This type of hearing loss is due to problems in the inner ear or auditory nerve, which can be partially compensated for by using hearing aids. The other choices, A: Conductive, B: Mixed, and D: Central, are not as effectively improved by hearing aids. Conductive hearing loss is usually due to problems in the outer or middle ear, which can often be treated with medical or surgical interventions. Mixed hearing loss involves a combination of conductive and sensorineural components, and may require a combination of interventions. Central hearing loss is due to problems in the central auditory pathways in the brain, and is not typically improved by hearing aids.