ATI RN
Nursing Process Test Questions Questions
Question 1 of 5
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 2 of 5
Which of the ff nursing interventions ensure that a client with Hodgkin’s disease remains free of infection? Choose all that apply
Correct Answer: C
Rationale: Rationale: C: Practice conscientious hand washing is correct as it helps prevent the spread of infection. Proper hand hygiene is essential in reducing the risk of infection transmission to the client with Hodgkin's disease. A: Apply ice to the skin for brief periods is incorrect as it does not directly relate to preventing infection in the client. B: Provide cool sponge baths is incorrect as it mainly addresses comfort and hygiene but does not specifically target infection prevention. D: Use cotton gloves Restrict visitors or personnel with infections from contact with the client is incorrect because while using gloves can help prevent the spread of infection, restricting visitors with infections is not under the direct control of the nurse. Summary: Practicing conscientious hand washing is crucial in preventing infection in a client with Hodgkin's disease, while the other choices do not directly address infection control in this context.
Question 3 of 5
When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
Correct Answer: B
Rationale: The correct answer is B: Hives or rashes. In autoimmune disorders, the immune system mistakenly attacks the body's own tissues, leading to various symptoms. Hives or rashes are common manifestations of autoimmune disorders due to the immune response affecting the skin. Other choices are incorrect because hypotension is not typically associated with autoimmune disorders, localized inflammation may be present but is not specific to autoimmune disorders, and cramping and vomiting are not primary signs of autoimmune disorders.
Question 4 of 5
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 5
Which of the ff is the primary sign of breast cancer?
Correct Answer: D
Rationale: The correct answer is D: A painless mass in the breast. This is the primary sign of breast cancer because most breast cancers present as painless lumps or masses. This is due to the abnormal growth of cells forming a tumor. Other choices (A, B, C) are also signs of breast cancer, but they are not as common or primary as the presence of a painless mass. A bloody discharge from the nipple (A) can be a sign of a benign condition or cancer, but it is not the most common presentation. Nipple retraction (B) and dimpling of the skin over the lesion (C) can also be signs of breast cancer, but they usually occur in later stages of the disease. Therefore, the presence of a painless mass in the breast is the primary sign that should raise suspicion for breast cancer.
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