ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 9
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
Correct Answer: A
Rationale: The correct answer is A: Assessment. The nurse made an error in the assessment phase by not communicating the patient's condition promptly. Assessment involves collecting data and recognizing changes in the patient's condition. By not informing the nurse about feeling dizzy and light-headed, the nurse missed crucial information that could have indicated a deteriorating condition. The other choices are incorrect because: B: Diagnosis comes after assessment and involves analyzing data to identify the patient's problems. C: Implementation is the phase where nursing interventions are carried out based on the diagnosis. D: Evaluation is the final phase where the nurse assesses the effectiveness of interventions and outcomes.
Question 2 of 9
A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct: 1. Safety: Morbidly obese patients are at higher risk of falls during transfers. 2. Assistance: Having two other personnel ensures safe transfer. 3. Weight distribution: Distributing the patient's weight among multiple helpers reduces strain. 4. Proper body mechanics: Allows for proper positioning and technique while assisting. Summary of why other choices are incorrect: B. Medication doesn't address the safety concern of transferring a morbidly obese patient. C. Reviewing activity orders is not the immediate action needed for the patient's first bathroom transfer. D. Offering a walker may not provide sufficient support for a morbidly obese patient during the transfer.
Question 3 of 9
The nurse teaches a diabetic client that diet plays a crucial role in managing diabetes mellitus. When evaluating dietary intake, the nurse knows the client is eating the right foods if total daily caloric intake consists of:
Correct Answer: C
Rationale: The correct answer is C (50% to 55% carbohydrate, 35% fat, and 10% to 15% protein) for managing diabetes. Carbohydrates impact blood sugar levels the most, so a moderate intake is crucial. The fat percentage is lower to reduce the risk of cardiovascular issues, common in diabetics. Protein intake is moderate for muscle maintenance. Choice A has higher fat and lower carbohydrate, not ideal for diabetes. Choice B has too high carbohydrate, which can spike blood sugar. Choice D has the highest carbohydrate percentage, which is not recommended for diabetes management.
Question 4 of 9
Which nursing diagnosis is most appropriate for a client with Addison’s disease?
Correct Answer: C
Rationale: The correct answer is C, Excessive fluid volume. In Addison's disease, there is a deficiency of cortisol and aldosterone leading to sodium loss and water retention. This imbalance can result in excessive fluid volume. A) Risk for infection is not directly related to Addison's disease. B) Urinary retention is not a common symptom of Addison's disease. D) Hypothermia is not a typical manifestation of Addison's disease.
Question 5 of 9
A female client with lymphedema expresses her anxiety about the abnormal enlargement of an arm. Which of the ff suggestions should a nurse give to support the clients self image?
Correct Answer: C
Rationale: The correct answer is C: Introduce variations in styles of clothing. This suggestion promotes the client's self-image by helping her feel more comfortable and confident in her appearance despite the lymphedema. It allows her to express her personal style while accommodating the enlarged arm. A: Placing the arm in a sling does not address the client's self-image concerns and may further highlight the abnormality. B: Applying cold soaks may help with swelling but does not directly address the client's self-image. D: Tying a tight bandage can worsen lymphedema and does not address the client's self-image concerns.
Question 6 of 9
What is an important consideration regarding TPN administration?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Aseptic technique prevents infection at IV site. 2. TPN is a high-risk solution, requiring strict aseptic administration. 3. Contaminated site can lead to sepsis or other serious complications. 4. Choice B increases risk of contamination. 5. Choice C increases risk of bacterial growth. 6. Choice D may introduce air or contamination. Summary: Choice A is correct as it emphasizes infection prevention. Choices B, C, and D pose risks of contamination, bacterial growth, or air introduction.
Question 7 of 9
Clients will go through operations and who have undergone surgery need the proper observation, treatment, and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria is preparing Mr. Sy for surgery. Which of the following statements by the client would indicate he is well-informed about his imminent surgery?
Correct Answer: B
Rationale: The correct answer is B. Mr. Sy's statement indicates he understands the pre-operative fasting instructions, which is crucial to prevent aspiration during surgery. Not eating after midnight reduces the risk of complications. A: Incorrect. Wearing a pneumatic compression device post-surgery is important, but this statement does not demonstrate understanding of pre-surgery preparations. C: Incorrect. Knowing the skin preparation site size does not indicate understanding of the surgery process. D: Incorrect. Signing the consent form at the operating table may indicate lack of understanding of the consent process and timing. In summary, choice B is correct as it shows Mr. Sy's awareness of the fasting requirement before surgery, which is crucial for a safe operation.
Question 8 of 9
Aling Maria, a 58-year old female, was admitted for the third time because of myxedema. Initial assessment by Nurse Mida should include symptoms of:
Correct Answer: C
Rationale: The correct answer is C. Aling Maria is admitted for myxedema, which is severe hypothyroidism. Symptoms of hypothyroidism include lethargy, weight gain, slow speech, and decreased respiratory rate. Bradycardia, weight loss, heart failure, and diarrhea are not typical symptoms of myxedema. Tachycardia, constipation, and exopthalmus are more commonly associated with hyperthyroidism. Hypothermia, weight loss, and increased respiratory rate are not consistent with myxedema. Thus, choice C is the most appropriate initial assessment for Aling Maria.
Question 9 of 9
A client with HIV has been prescribed anti viral medications. What instructions related to administration of medications should the nurse give such a client?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Timing: Antiviral medications should be taken as prescribed to maintain consistent drug levels in the body. 2. Around meals: Taking medications with or without food can affect absorption, so timing around meals helps with consistency. 3. Compliance: Following the timing instructions increases medication effectiveness and reduces the risk of drug resistance. Other Choices: B) Avoiding harsh sunlight: Not directly related to medication administration; may be a precaution for other reasons. C) Having medications with fruit juice: This is not a standard instruction for antiviral medications; may not be suitable for all medications. D) Increasing dose for worsening symptoms: This is dangerous and should only be done under healthcare provider supervision; self-adjusting medication doses can be harmful.