ATI RN
Nursing Process Test Questions Questions
Question 1 of 9
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
Correct Answer: C
Rationale: The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage. A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin. B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers. D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.
Question 2 of 9
Which action by the nurse is appropriate?
Correct Answer: A
Rationale: The correct answer is A because observing the patient for abnormal bleeding is an appropriate action to monitor for potential complications of warfarin therapy. This aligns with the nursing role in assessing and monitoring patient responses to treatment. B is incorrect as increasing warfarin dose without physician order can lead to adverse effects. C is incorrect as altering the dose without medical advice can be dangerous. D is incorrect as administering Vitamin K would counteract the effects of warfarin, which is used to prevent blood clotting.
Question 3 of 9
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
Correct Answer: D
Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.
Question 4 of 9
After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?
Correct Answer: B
Rationale: The correct answer is B. Administering epinephrine is the first-line treatment for anaphylactic shock to reverse hypotension and bronchoconstriction. Intubation may be necessary if airway compromise occurs despite epinephrine. Paging an anesthesiologist (A) is not the priority. Administering penicillin antidote (C) is not indicated in anaphylaxis. Inserting a urinary catheter and infusing IV fluids (D) may be necessary later but not the priority in managing anaphylactic shock.
Question 5 of 9
When performing a neurological examination on Mr. RR, which of the following would not be considered an important or useful part of the examination?
Correct Answer: D
Rationale: The correct answer is D because pupil size is not typically a part of a routine neurological examination. A: Eye movements are assessed to evaluate cranial nerve functions. B: Reflexes help determine the integrity of the spinal cord and peripheral nervous system. C: Nuchal rigidity is important to assess for signs of meningitis or other neurological conditions. In contrast, pupil size is more relevant in ophthalmological examinations or when assessing response to specific medications affecting the pupil size.
Question 6 of 9
The dietary practice that will help a client reduce the dietary intake of sodium is
Correct Answer: C
Rationale: The correct answer is C: Avoiding the use of carbonated beverages. Carbonated beverages often have high sodium content, which can contribute to increased sodium intake. By avoiding these beverages, the client can significantly reduce their sodium consumption. Explanation: 1. Carbonated beverages often contain added sodium for flavor enhancement. 2. By avoiding carbonated beverages, the client eliminates a significant source of hidden sodium in their diet. 3. This dietary practice directly targets reducing sodium intake without compromising other nutritional aspects of the diet. Summary of other choices: A: Increasing the use of dairy products - Dairy products do not necessarily impact sodium intake significantly. B: Using an artificial sweetener in coffee - Artificial sweeteners do not contribute to sodium intake. D: Using catsup for cooking and flavoring food - Catsup is high in sodium and would not help in reducing sodium intake.
Question 7 of 9
A client has been diagnosed with renal failure and is admitted for dialysis. Which of the ff is the nurse’s responsibility as the client undergone dialysis?
Correct Answer: C
Rationale: The correct answer is C: Weighing the client before and after the procedure. This is crucial as it helps monitor fluid removal during dialysis, ensuring the process is effective and safe. Weighing helps determine if the correct amount of fluid has been removed. A: Keeping dialysis supplies in a clean area is important for infection control but not a direct responsibility during the procedure. B: Inspecting the catheter insertion site for signs of infection is essential for monitoring the site's health but not a direct responsibility during dialysis. D: Washing hands before and after handling the catheter is a general infection control measure but not specific to the dialysis procedure itself.
Question 8 of 9
One of the side effects of INH administration is peripheral neuropathy. To prevent this effect, Nurse Carlos teaches Andrew to:
Correct Answer: C
Rationale: Step-by-step rationale: 1. INH (Isoniazid) can lead to peripheral neuropathy due to vitamin B6 deficiency. 2. Pyridoxine is vitamin B6, which helps prevent neuropathy. 3. Supplementing with pyridoxine can counteract the deficiency caused by INH. 4. Thus, option C, supplementing the diet with pyridoxine, is the correct choice. Summary: - Option A is incorrect as a low cholesterol diet does not address the vitamin B6 deficiency. - Option B is incorrect as excessive bed rest does not prevent neuropathy. - Option D is incorrect as sun exposure is not related to the prevention of peripheral neuropathy.
Question 9 of 9
The nurse knows that Parkinson’s disease a progressive neurologic disorder is characterized by:
Correct Answer: D
Rationale: The correct answer is D. Parkinson's disease is characterized by bradykinesia, tremor, and muscle rigidity. Bradykinesia refers to slowness of movement, tremor involves involuntary shaking, and muscle rigidity causes stiffness and resistance to movement. These three symptoms are commonly known as the classic triad of Parkinson's disease. Therefore, selecting "All of the above" (D) is the correct choice as it encompasses all the key features of Parkinson's disease. Choices A, B, and C individually are incorrect because they do not fully capture the comprehensive presentation of symptoms in Parkinson's disease.