ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
The client is a type II DM patient. The client asks the nurse what is the primary reason a type II diabetic does not usually develop diabetic ketoacidosis?
Correct Answer: C
Rationale: Rationale for Choice C (Correct answer): - In type II DM, there is some insulin present but it is insufficient to meet the body's needs. - Without sufficient insulin, the body turns to breaking down protein and fatty acids for energy. - This leads to the formation of ketones, which can lead to diabetic ketoacidosis (DKA). - Therefore, the primary reason a type II diabetic does not usually develop DKA is due to insufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs. Summary of other choices: - Choice A is incorrect because there is some insulin available in type II DM, though it may be insufficient. - Choice B is incorrect as type II diabetics do have fat and protein reserves. - Choice D is incorrect as insufficient serum glucose concentrations do not directly relate to the development of DKA in type II DM.
Question 2 of 5
The nurse understands that for the parathyroid hormone to exert its effect, what must be present?
Correct Answer: D
Rationale: The correct answer is D: Increased calcium level. Parathyroid hormone functions to increase blood calcium levels. When calcium levels are low, the parathyroid gland releases PTH to stimulate the release of calcium from bones and increase calcium absorption from the intestines and kidneys. This helps to maintain normal calcium levels in the blood. Choices A, B, and C are incorrect because decreased phosphate level, functioning thyroid gland, and adequate vitamin D level are not direct requirements for the action of parathyroid hormone.
Question 3 of 5
When teaching a client about insulin therapy, the nurse should instruct the client to avoid which over-the- counter preparation that can interact with insulin?
Correct Answer: D
Rationale: The correct answer is D: Salicylate preparations. Salicylate can potentiate the effects of insulin, leading to hypoglycemia. Therefore, the nurse should instruct the client to avoid this over-the-counter preparation when on insulin therapy. Antacids (A), vitamins with iron (B), and acetaminophen preparations (C) do not typically interact with insulin in a significant way.
Question 4 of 5
Which of the following statements about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
Correct Answer: D
Rationale: The correct answer is D because in HHNS, the primary goal is to gradually correct dehydration without causing fluid overload. Administering IV fluid slowly helps prevent circulatory overload and collapse. Choice A is incorrect as rapid administration can lead to fluid overload and electrolyte imbalances. Choice B is incorrect as 6L over 24 hours is excessive and can cause fluid overload. Choice C is incorrect as dextrose solution with normal saline is not the ideal fluid replacement for this condition.
Question 5 of 5
When caring for Mr. Reyes, the nurse should assess for
Correct Answer: B
Rationale: The correct answer is B: Altered level of consciousness. This is crucial as it can indicate various underlying health issues affecting Mr. Reyes. Assessing for this helps in detecting potential neurological, metabolic, or cardiac issues. A: Decreased carotid pulses - While important, it is not as critical as altered level of consciousness in this scenario. C: Bleeding from oral cavity - This is important to address but does not take priority over assessing Mr. Reyes' level of consciousness. D: Absence of deep tendon-reflexes - This is more specific to neurological assessments and may not be as urgent as assessing his level of consciousness.