ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 9
One of the dangers of treating hypernatremia is:
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. Hypernatremia is an elevated sodium level in the blood, which can lead to osmotic shifts causing water to move out of cells, including brain cells. This can result in cerebral edema, potentially leading to neurological complications. Incorrect choices: A: Red blood cell crenation - This occurs in hypertonic solutions, not hypernatremia. C: Red blood cell hydrolysis - Hypernatremia doesn't directly cause red blood cell hydrolysis. D: Renal shutdown - Hypernatremia can stress the kidneys, but it doesn't typically lead to renal shutdown.
Question 2 of 9
A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
Correct Answer: C
Rationale: The correct answer is C. This statement warrants clarification as donating blood does not put individuals at risk of getting HIV. Blood donation involves a sterile process that ensures safety. Choice A is correct as using condoms can help prevent the transmission of HIV. Choice B is incorrect because modern blood screening techniques have greatly reduced the risk of HIV transmission through blood transfusions. Choice D is also correct as sharing needles is a high-risk behavior for HIV transmission. In summary, only choice C is incorrect as donating blood does not pose a risk of acquiring HIV.
Question 3 of 9
A nurse is conducting a nursing health history. Which component will the nurse address?
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, the nurse focuses on gathering information about the patient's health concerns, medical history, lifestyle, and expectations for their care. Addressing patient expectations is crucial for providing patient-centered care and establishing a therapeutic relationship. The other choices are incorrect because: A: Nurse's concerns are not the primary focus of a nursing health history. C: Current treatment orders are important but are typically addressed during a physical assessment or when implementing care. D: Nurse's goals for the patient are important but should be developed in collaboration with the patient based on their needs and preferences.
Question 4 of 9
What dietary advice should the nurse give to clients with HIV/AIDS?
Correct Answer: D
Rationale: The correct answer is D: Decrease the intake of trace elements and antioxidant supplements. Clients with HIV/AIDS do not require additional trace elements and antioxidant supplements, as excessive intake can be harmful. HIV/AIDS already places stress on the immune system, so taking excessive supplements may lead to toxicity. It is important to focus on a balanced diet rich in essential nutrients rather than overloading the body with unnecessary supplements. Encouraging a healthy, balanced diet will help support overall health and immune function in clients with HIV/AIDS. Choices A, B, and C are incorrect because encouraging excessive intake of fat-soluble vitamins, water-soluble vitamins, iron, and zinc can also lead to potential adverse effects. It is important to focus on meeting the recommended daily allowances for these nutrients rather than exceeding them.
Question 5 of 9
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
Correct Answer: D
Rationale: The correct answer is D: Proper positioning. Proper positioning helps maintain joint alignment, prevents pressure ulcers, and reduces the risk of contractures by keeping the muscles in a neutral position. This is crucial in preventing complications associated with spasticity. A: Active exercise may exacerbate spasticity and lead to muscle fatigue, increasing the risk of contractures. B: Use of tilt board may not directly address the need for proper positioning to prevent contractures. C: Deep massage may provide temporary relief but does not address the underlying issue of maintaining proper positioning to prevent contractures.
Question 6 of 9
A nurse is conducting a nursing health history. Which component will the nurse address?
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for their health care. By focusing on the patient's expectations, the nurse can establish a therapeutic relationship, provide patient-centered care, and tailor the care plan accordingly. A: Nurse's concerns - Incorrect. The nursing health history should prioritize the patient's perspective and needs over the nurse's concerns. C: Current treatment orders - Incorrect. While important, this component focuses on the medical treatment plan rather than the patient's expectations. D: Nurse's goals for the patient - Incorrect. The nurse should collaborate with the patient to set goals that align with the patient's needs and preferences, not impose their own goals.
Question 7 of 9
A nurse evaluates a client’s response to a nursing intervention and determines that the expected outcome was not achieved. What is the nurse’s most appropriate action?
Correct Answer: D
Rationale: The correct answer is D: Reassess the client's condition. When an expected outcome is not achieved, the nurse must reassess the client's condition to identify the reasons for the lack of success. This step allows the nurse to gather more information, adjust the plan of care if necessary, and determine the most suitable course of action to help the client achieve the desired outcome. Choice A: Terminating the plan of care is premature without reassessing the client's condition and identifying potential barriers to success. Choice B: Modifying the plan of care may be necessary after reassessment but should not be the first step. Choice C: Reassigning care to another nurse does not address the underlying issues affecting the client's response to the intervention.
Question 8 of 9
During the initial assessment, he is placed in a modified Trendelenburg position. What desired effect should the position have on the client?
Correct Answer: A
Rationale: The modified Trendelenburg position involves placing the client with their legs elevated higher than their head. This position promotes venous return to the heart, increasing preload and cardiac output, thereby leading to an increase in blood pressure. Elevating the legs helps to reduce peripheral edema and improve circulation. Therefore, the correct answer is A. Choice B is incorrect because the Trendelenburg position does not directly affect the respiratory rate. Choice C is incorrect as the position is not intended to increase heart rate but rather improve venous return. Choice D is also incorrect as the primary goal of the Trendelenburg position is not to decrease blood loss, although it may help in some cases by improving circulation.
Question 9 of 9
Which of the ff is the potential complication the nurse should monitor for when caring for a client with acute respiratory distress syndrome?
Correct Answer: B
Rationale: The correct answer is B: Renal failure. Acute respiratory distress syndrome (ARDS) can lead to hypoxemia and respiratory acidosis, causing decreased perfusion to the kidneys and potentially leading to renal failure. Monitoring for signs of renal failure, such as decreased urine output and elevated creatinine levels, is crucial in managing clients with ARDS. Incorrect choices: A: Chest wall bulging is not a common complication of ARDS. It may be seen in conditions like tension pneumothorax. C: Difficulty swallowing is not a typical complication of ARDS. It may be seen in neurological conditions or esophageal disorders. D: Orthopnea is not a direct complication of ARDS. It is more commonly associated with heart failure or pulmonary edema.