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
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct: 1. Blood pressure is vital in this scenario due to prednisone discontinuation. 2. Abruptly stopping prednisone can lead to adrenal insufficiency. 3. Adrenal insufficiency can cause hypotension, a life-threatening condition. 4. Monitoring blood pressure can help detect and manage potential complications. Summary of other choices: A: Breath sounds – Important but not the priority in this specific situation. C: Capillary refill – Useful for assessing circulation but not urgent in this context. D: Butterfly rash – A characteristic of lupus, but not a critical concern in this scenario.
Question 3 of 5
Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
Correct Answer: A
Rationale: Step 1: Orthopnea is a classic symptom of congestive heart failure (CHF) due to fluid accumulation in the lungs when lying flat. Step 2: This symptom occurs because when lying down, the fluid redistributes, making it harder to breathe. Step 3: Fever (choice B) is not typically associated with CHF unless there is an underlying infection. Step 4: Weight loss (choice C) is more indicative of conditions like cancer or malnutrition, not CHF. Step 5: Calf pain (choice D) is more commonly associated with deep vein thrombosis, not CHF. Summary: Orthopnea is the best assessment finding indicating CHF, while the other choices are more likely related to different health conditions.
Question 4 of 5
A factory worker suffered a chemical burn to the eye and arrives at the Emergency department. What is the first action of the nurse?
Correct Answer: D
Rationale: The correct answer is D: flush the eye continuously with sterile solution. This is the first action because it helps to remove the chemical from the eye, preventing further damage. Flushing with sterile solution dilutes and washes away the chemical, reducing the risk of ongoing injury. Applying a cold compress (A) may help with pain but does not address the chemical exposure. Applying a bandage (B) can trap the chemical and worsen the injury. Performing an assessment (C) should come after immediate treatment to ensure proper care but should not delay flushing the eye.
Question 5 of 5
Mr. Boy, a 65-year old man, has been admitted wth severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include:
Correct Answer: B
Rationale: The correct answer is B: a semi-private room. For a burn patient like Mr. Boy, a semi-private room is preferred to provide a more controlled environment for infection prevention, wound care, and privacy. Strict isolation (A) is not necessary as his burns are not infectious. Liberal visiting (C) can increase the risk of infection and compromise his recovery. Sharing equipment (D) can lead to cross-contamination and is not recommended for burn patients. In summary, a semi-private room balances infection control and patient comfort for burn patients.