ATI RN
Nursing Process Practice Questions Questions
Question 1 of 9
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 2 of 9
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 3 of 9
The nurse is caring for a client in the emergency room diagnosed with Bell’s palsy. The client has been taking acetaminophen (Tylenol), and acetaminophen overdose is suspected. The nurse anticipates that the antidote to be prescribed is:
Correct Answer: D
Rationale: Rationale: Acetylcysteine (Mucomyst) is the antidote for acetaminophen overdose. It works by replenishing glutathione, which helps neutralize the toxic metabolite of acetaminophen. Pentostatin, Fludarabine, and Auranofin are not antidotes for acetaminophen overdose and are used for different conditions. Acetylcysteine is the correct choice as it directly counteracts the toxic effects of acetaminophen.
Question 4 of 9
A patient has iron deficiency anemia. Which of the following foods will best help provide dietary iron?
Correct Answer: C
Rationale: The correct answer is C: Lean red meats. Lean red meats are a rich source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Heme iron helps improve iron levels more effectively in individuals with iron deficiency anemia. Fresh fruits (A) and dairy products (B) contain minimal iron, while breads and cereals (D) provide non-heme iron which is not as readily absorbed.
Question 5 of 9
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
Correct Answer: D
Rationale: The correct answer is D because developing a formal nursing diagnosis helps nurses focus on their scope of practice, which includes identifying and addressing the patient's nursing care needs. By formulating a clear nursing diagnosis, nurses can prioritize interventions that are within their domain of expertise. This ensures efficient and effective patient care delivery. A: Incorrect. Developing a nursing diagnosis is not about creating a language exclusive to nurses; it is about identifying patient care needs. B: Incorrect. While nursing diagnoses do delineate the nurse's role, the primary purpose is not to distinguish it from the physician's role. C: Incorrect. Nursing diagnoses are based on evidence and critical thinking, not solely on intuition or others' judgments.
Question 6 of 9
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Correct Answer: D
Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.
Question 7 of 9
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B because focusing on the patient's presenting situation is the first step in the problem-oriented approach. This allows the nurse to gather relevant data related to the current health issue, which is crucial for identifying the problem and formulating a care plan. Option A is incorrect as chronological order may not prioritize the most critical data. Option C is incorrect as interpretations come after data collection. Option D is incorrect as observation typically follows data collection and analysis. Focusing on the patient's presenting situation ensures efficient and effective data collection for problem-solving.
Question 8 of 9
Which of the ff. medications might be ordered to help control symptoms of multiple sclerosis, and possibly induce a remission?
Correct Answer: C
Rationale: Correct Answer: C - ACTH Rationale: 1. ACTH (adrenocorticotropic hormone) can help control symptoms and induce remission in multiple sclerosis by reducing inflammation. 2. ACTH stimulates the production of cortisol, a natural anti-inflammatory hormone. 3. By reducing inflammation in the central nervous system, ACTH can help manage symptoms and promote remission. Summary of other choices: A: Acyclovir - Antiviral medication used to treat herpes infections, not effective for multiple sclerosis. B: Thyrotropin - Hormone that stimulates thyroid function, not used in the treatment of multiple sclerosis. D: Benadryl - Antihistamine used for allergies and itching, not indicated for multiple sclerosis management.
Question 9 of 9
Which of the following actions should the nurse take to maintain patient safety when ambulating a patient for the first time postoperatively?
Correct Answer: B
Rationale: The correct answer is B: Use two people to assist the patient. This is the safest option as it provides optimal support and stability for the patient during their first postoperative ambulation. Two people can help prevent falls, ensure proper body mechanics, and offer immediate assistance if needed. Using one person (choice A) may not provide enough support. Encouraging the patient to "dangle" (choice C) may increase the risk of orthostatic hypotension. Giving a narcotic before ambulation (choice D) can impair the patient's balance and coordination, increasing the risk of falls.