ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 5
Nursing assessment for a patient with metabolic alkalosis includes evaluation of laboratory data for all of the following except:
Correct Answer: C
Rationale: The correct answer is C: Hypoglycemia. In metabolic alkalosis, the blood pH is elevated due to an excess of bicarbonate. Hypoglycemia is not directly related to metabolic alkalosis but can be seen in other conditions like diabetes or fasting. Evaluating for hypocalcemia (A) is important as alkalosis can lead to decreased ionized calcium levels. Hypokalemia (B) is common in metabolic alkalosis due to potassium loss. Hypoxemia (D) is not directly related to metabolic alkalosis but can occur in severe cases due to respiratory compensation. Therefore, hypoglycemia is the least relevant in assessing metabolic alkalosis.
Question 2 of 5
Which patient is most at risk for fluid volume overload?
Correct Answer: C
Rationale: The correct answer is C, the 35-year-old with kidney failure. Patients with kidney failure are at high risk for fluid volume overload due to the kidneys' inability to properly regulate fluid balance. This can lead to accumulation of excess fluids in the body, causing edema, hypertension, and heart failure. In contrast, choices A, B, and D are not at as high risk for fluid volume overload as patients with kidney failure, as their conditions do not directly impact fluid regulation in the body.
Question 3 of 5
Which of the following symptoms most likely indicates that an infusion is infiltrated?
Correct Answer: C
Rationale: The correct answer is C: Puffiness at the site. This indicates infiltration of the infusion, where the medication or fluid leaks into the surrounding tissue instead of entering the bloodstream. Puffiness is a sign of fluid accumulation due to the infiltration. Redness at the site (A) may indicate infection, pain (B) can be due to various reasons, and exudate (D) may suggest infection or irritation, but they are not specific to infiltration. Infiltration assessment involves checking for swelling, coolness, and blanching around the infusion site.
Question 4 of 5
Which of the ff symptoms should a nurse assess in a client when implementing interventions for trauma to the upper airway?
Correct Answer: D
Rationale: The correct answer is D: Presence of laryngospasm. Laryngospasm is a serious complication of trauma to the upper airway that can lead to airway obstruction. Assessing for laryngospasm is crucial to ensure the client's airway remains patent. Pain when talking (A) is more related to vocal cord injury, increased nasal swelling (B) is a symptom of nasal trauma, and burning in the throat (C) may indicate pharyngeal injury, but laryngospasm (D) directly affects airway patency in upper airway trauma cases.
Question 5 of 5
Which of the ff nursing interventions is involved when caring for a client with influenza?
Correct Answer: C
Rationale: The correct answer is C: Immediate recognition of respiratory distress. This is crucial when caring for a client with influenza as the virus can lead to respiratory complications. Prompt recognition allows for timely intervention and prevents further deterioration. A: Maintaining airborne transmission is incorrect as the goal is to prevent the spread of influenza through droplet precautions, not airborne transmission. B: Oxygen administration may be necessary for severe cases of influenza, but immediate recognition of respiratory distress takes precedence in the nursing interventions. D: Complete bed rest is not recommended for influenza as mobilization and deep breathing exercises are important to prevent complications like pneumonia.