ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 5
Place the following four nursing actions for the new laryngectomee in correct order of priority? i.Assist with ambulation ii.Set up a visit from a well-adjusted laryngectomee iii.Maintain a patent airway iv.Control postoperative pain
Correct Answer: C
Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.
Question 2 of 5
Which of the following is the medication of choice for anaphylaxis that the nurse should anticipate would be ordered?
Correct Answer: A
Rationale: The correct answer is A: Epinephrine. In anaphylaxis, epinephrine is the medication of choice due to its rapid onset of action and ability to reverse severe allergic reactions. It acts by constricting blood vessels, increasing heart rate, and opening airways. This helps counteract the dangerous drop in blood pressure and airway constriction seen in anaphylaxis. Digoxin, theophylline, and furosemide are not appropriate for anaphylaxis as they do not address the immediate life-threatening symptoms of anaphylaxis.
Question 3 of 5
Which of the ff nursing interventions would a nurse perform to avoid maceration from irritating drainage or the wound compresses in a client with breast abscess?
Correct Answer: A
Rationale: The correct answer is A: Apply zinc oxide to the surrounding skin. This intervention helps create a protective barrier between the irritating drainage or wound compresses and the skin, thus preventing maceration. Zinc oxide has moisture-repelling properties that can help keep the skin dry and reduce the risk of maceration. Choice B (Using a binder) may not address the root cause of maceration and could potentially increase pressure on the wound site. Choice C (Supporting the arm and shoulder with pillows) may provide comfort but does not directly prevent maceration. Choice D (Instructing the client not to shave axillary hair) is unrelated to preventing maceration from irritating drainage or wound compresses.
Question 4 of 5
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
Correct Answer: D
Rationale: The correct answer is D. Asking the patient about usual sleep patterns and the onset of having difficulty resting is the best action for the nurse to take. This allows the nurse to gather more information and assess if there is a possible correlation between the leg cast and the restless sleep. It is important to consider all aspects of the patient's condition and not dismiss any symptoms. Choice A is incorrect because telling the patient to just focus on the leg and cast disregards the patient's concerns about restless sleep. Choice B is incorrect as simply documenting the information without further assessment does not address the patient's issue. Choice C is incorrect as postponing a thorough assessment to the next shift may delay necessary intervention for the patient's sleep problem.
Question 5 of 5
Why should the nurse wake up a client who is to undergo an EEG at midnight?
Correct Answer: B
Rationale: The correct answer is B because optimum sleep helps regulate breathing patterns during an EEG. Waking the client at midnight allows them to have a full night's rest, ensuring they are well-rested and their breathing is stable for accurate EEG results. Choice A is incorrect as excess sleep does not affect nervousness. Choice C is incorrect as waking the client does not help them fall asleep naturally during the EEG. Choice D is incorrect as headache prevention is not directly related to waking the client at midnight.
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