ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
The lowest fasting plasma glucose level suggestive of a diagnosis of diabetes is:
Correct Answer: B
Rationale: The correct answer is B (126mg/dl) because a fasting plasma glucose level ≥126mg/dl is diagnostic of diabetes. The diagnostic criteria for diabetes include a fasting plasma glucose level ≥126mg/dl on two separate occasions. Choices A, C, and D are incorrect because they do not meet the diagnostic threshold for diabetes. A (90mg/dl) is within the normal range, C (115mg/dl) is elevated but not diagnostic, and D (180mg/dl) is too high but not necessary for diagnosis. It's crucial to understand the specific diagnostic criteria to accurately identify diabetes.
Question 2 of 5
The best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:
Correct Answer: D
Rationale: The correct answer is D, "Chest and nostrils." This is because observing the movement of the chest and nostrils is the most reliable way to determine if a patient is breathing. The chest rises and falls with each breath, and the nostrils may flare or move as air is inhaled and exhaled. Monitoring these areas provides a direct indication of respiratory effort. Choices A, B, and C are incorrect because they do not directly reflect the act of breathing. Extremities, head, and eyeball movements are not reliable indicators of breathing function.
Question 3 of 5
Mr. Reyes has a possible skull fracture. The nurse should:
Correct Answer: A
Rationale: The correct answer is A because observing for signs of brain injury is crucial in assessing a possible skull fracture. Signs may include altered mental status, headache, nausea, vomiting, and unequal pupil size. Choice B is incorrect as hemorrhaging from the oral cavity may not always be present in skull fractures. Choice C is incorrect as elevating the foot of the bed is not recommended for a possible skull fracture. Choice D is incorrect as decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.
Question 4 of 5
A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Anxiety related to barium enema. This is the correct choice because nursing diagnoses should focus on the patient's actual or potential health problems, not just medical conditions. Anxiety is a common response to medical procedures like a barium enema. It is essential for the nurse to address the patient's emotional and psychological needs. Summary: B: Impaired gas exchange related to asthma is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on the patient's response to the medical condition. C: Impaired physical mobility related to incisional pain is a potential nursing diagnosis, but the focus should be on the patient's response to the pain, not just the pain itself. D: Nausea related to adverse effect of cancer medication is also a medical diagnosis. Nursing diagnoses should address the patient's response to the medication side effects, not just the side effects themselves.
Question 5 of 5
Which of the following intravenous solutions is hypotonic?
Correct Answer: C
Rationale: The correct answer is C: 0.45% saline. This solution is hypotonic because it has a lower osmolarity compared to the intracellular fluid. It contains fewer solutes than the cells, causing water to move into the cells by osmosis, potentially causing them to swell. Normal saline (A) and Ringer's lactate (B) are isotonic solutions, meaning they have a similar osmolarity to the intracellular fluid and do not cause significant water shifts. 5% dextrose in normal saline (D) is a hypertonic solution, containing more solutes than the cells, leading to water movement out of the cells.
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