ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 9
The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
Correct Answer: D
Rationale: The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions." Rationale: 1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being. 2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery. 3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient. 4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes. Summary: A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs. B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses. C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.
Question 2 of 9
A client with Hashimoto’s thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Because of the client’s cardiac history, the nurse would expect that the client’s initial dose for the thyroid replacement would be which of the following?
Correct Answer: A
Rationale: The correct answer is A: 25 g/day, initially. In this scenario, the client with Hashimoto's thyroiditis and a history of cardiac issues requires a cautious approach due to the risk of exacerbating cardiac conditions with thyroid hormone replacement. Starting with a low dose of 25 µg/day allows for careful monitoring of the client's response and prevents potential adverse effects on the cardiovascular system. Summary: B: Delayed until after thyroid surgery - Not appropriate as the client requires thyroid replacement therapy for Hashimoto's thyroiditis. C: 100 µg/day, initially - Too high of an initial dose and may lead to adverse cardiovascular effects. D: Initiated before thyroid surgery - Not relevant to the client's situation as there is no indication for thyroid surgery mentioned in the question.
Question 3 of 9
Which of the ff. safety instructions should the nurse give a patient who has temporarily dilated pupils?
Correct Answer: B
Rationale: The correct answer is B: Wear sunglasses. Dilated pupils are sensitive to light, so wearing sunglasses can help protect the eyes from excessive light exposure. Keeping the eyes closed (A) may provide temporary relief but does not protect the eyes from light. Avoiding driving for 8 hours (C) is important after certain eye procedures but not specifically related to dilated pupils. Avoiding caffeinated beverages (D) is unrelated to pupil dilation.
Question 4 of 9
25-year old Francisco M., is diagnosed as having myelocytic leukemia and is admitted for chemotherapy. Francisco M.’s laboratory results indicate bone marrow depression. The nurse should encourage him to:
Correct Answer: B
Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because: A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression. C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding. D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.
Question 5 of 9
A patient asks the nurse what side effects to expect from a muscle relaxant medication that has been prescribed. Which of the ff. side effects should the nurse relate?
Correct Answer: B
Rationale: The correct answer is B: Drowsiness. Muscle relaxants can cause drowsiness as a common side effect due to their sedative properties. This can impair alertness and coordination, so it's crucial for the patient to be aware of this potential effect. Choice A, hypoglycemia, is not typically associated with muscle relaxants. Choice C, hypotension, is more commonly linked to medications like antihypertensives. Choice D, dyspnea, which is difficulty breathing, is not a common side effect of muscle relaxants. Therefore, the nurse should primarily focus on educating the patient about the potential side effect of drowsiness.
Question 6 of 9
The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
Correct Answer: C
Rationale: The correct answer is C: Take piroxicam with food or oral antacid. This instruction helps to reduce GI irritation by providing a protective barrier for the stomach lining. Piroxicam is known to cause GI upset due to its effect on prostaglandin synthesis. Taking it with food or an antacid can help minimize this side effect. Choice A (Space the administration every 4 hours) does not address the issue of GI irritation and is not a recommended strategy for preventing this side effect. Choice B (Use the drug for a short time only) is not a direct intervention to prevent GI upset and does not provide guidance on how to manage the side effect when taking the medication. Choice D (Decrease the piroxicam dosage) may not be necessary if the client can manage the side effects with the simple intervention of taking it with food or an antacid.
Question 7 of 9
A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
Correct Answer: D
Rationale: The correct answer is D, the Western blot test with ELISA. First, ELISA is used as a screening test for HIV antibodies. If positive, a confirmatory test like Western blot is needed to detect specific antibodies. Western blot is highly specific and confirms the presence of HIV antibodies. E-rosette immunofluorescence is not typically used for HIV diagnosis. Quantification of T-lymphocytes is used to monitor disease progression in HIV but does not confirm HIV infection. ELISA alone is not confirmatory; it needs to be followed by a more specific test like Western blot.
Question 8 of 9
The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?
Correct Answer: B
Rationale: The correct answer is B: Asymmetry. In the ABCD method for assessing skin lesions, A stands for asymmetry, which refers to whether one half of the lesion looks different from the other half. This is important because asymmetrical lesions are more likely to be cancerous. Actinic (choice A) refers to sun damage, Arcus (choice C) refers to a condition affecting the eyes, and Assessment (choice D) is a general term that does not specifically relate to the characteristics of skin lesions.
Question 9 of 9
A patient visiting with family members in the waiting area tells the nurse “I don’t feel good, especially in the stomach.” What should the nurse do?
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to return to the room, so the nurse can inspect the abdomen. Rationale: 1. Patient safety: By examining the patient's abdomen, the nurse can assess for any signs of distress or potential medical issues. 2. Patient-centered care: It is essential to prioritize the patient's well-being by addressing their concerns promptly and appropriately. 3. Professional responsibility: Nurses are trained to assess and evaluate patient symptoms to provide necessary care and support. Summary: A: Requesting the family to leave does not address the patient's symptoms and may disrupt the patient's support system. C: Asking about bowel movements and offering food may not be appropriate if the patient is experiencing stomach discomfort. D: Offering food without proper assessment may worsen the patient's condition and is not recommended before a proper evaluation.