ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 9
The nurse evaluates that furosemide IV is effective in treating pulmonary edema if which of the following patient signs or symptoms is resolved?
Correct Answer: B
Rationale: The correct answer is B: Pink, frothy sputum. This is because pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. Furosemide IV is a diuretic that helps remove excess fluid from the body, including the lungs. Resolving pink, frothy sputum indicates that the treatment is effectively reducing the fluid in the lungs. Incorrect choices: A: Pedal edema - This refers to swelling in the feet and ankles, which is not directly related to pulmonary edema. C: Jugular vein distention - This is a sign of heart failure, not specifically pulmonary edema. D: Bradycardia - This is a slow heart rate and not a direct indicator of pulmonary edema resolution.
Question 2 of 9
Why should the nurse wake up a client who is to undergo an EEG at midnight?
Correct Answer: B
Rationale: The correct answer is B because optimum sleep helps regulate breathing patterns during an EEG. Waking the client at midnight allows them to have a full night's rest, ensuring they are well-rested and their breathing is stable for accurate EEG results. Choice A is incorrect as excess sleep does not affect nervousness. Choice C is incorrect as waking the client does not help them fall asleep naturally during the EEG. Choice D is incorrect as headache prevention is not directly related to waking the client at midnight.
Question 3 of 9
The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?
Correct Answer: C
Rationale: The correct answer is C: Interdependent. In this scenario, the nurse performed an intervention for a collaborative problem, which involves working together with other healthcare professionals to address the issue. Interdependent interventions require collaboration and communication among healthcare team members to achieve the best outcomes for the patient. Choice A (Dependent Nursing) refers to interventions that require an order from a healthcare provider. Choice B (Independent) involves nursing actions that the nurse can initiate without the need for a healthcare provider's order. Choice D (Physician-initiated) specifically denotes interventions initiated by a physician without direct involvement from the nurse. In this case, the nurse's intervention for a collaborative problem aligns with the definition of interdependent intervention, making it the correct choice.
Question 4 of 9
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
Correct Answer: C
Rationale: The correct answer is C: Bluish urine. During lymphangiography, a contrast dye is injected into the lymphatic vessels, which can be excreted through the urine, causing it to appear bluish temporarily. This change is harmless and resolves on its own. Incorrect Answers: A: Purplish stools - This is not a common side effect of lymphangiography. B: Redness of the upper part of the feet - Redness is not typically associated with this procedure. D: Coldness of the soles - Coldness is not a known temporary change resulting from lymphangiography.
Question 5 of 9
. A client is admitted to the health care facility for evaluation for Addison’s disease. Which laboratory test result best supports a diagnosis of Addison’s disease?
Correct Answer: C
Rationale: Step-by-step rationale for choice C (Serum potassium level of 5.8 mEq/L) being the best to support a diagnosis of Addison's disease: 1. Addison's disease is characterized by adrenal insufficiency, leading to decreased aldosterone secretion. 2. Decreased aldosterone causes hyperkalemia due to impaired potassium excretion. 3. Elevated serum potassium levels above the normal range (3.5-5.0 mEq/L) are a classic finding in Addison's disease. 4. Therefore, a serum potassium level of 5.8 mEq/L strongly supports the diagnosis of Addison's disease. Summary: - Choice A (BUN level): BUN is not specific to Addison's disease and does not directly relate to adrenal function. - Choice B (Serum sodium level): Hyponatremia is a common finding in Addison's disease, but it is not as specific as hyperkalemia. - Choice D (Blood glucose level): Blood glucose
Question 6 of 9
A patient with a new diagnosis of lymphoma is experiencing fatigue. Which of the ff. is the best way to assess her fatigue?
Correct Answer: B
Rationale: The correct answer is B because having the patient rate her fatigue on a scale allows for a subjective assessment directly from the patient, providing valuable insight into the severity and impact of fatigue on her daily life. This approach considers the patient's perspective, which is crucial in understanding her experience and tailoring interventions. Choice A (observing activity level) may not accurately capture the subjective experience of fatigue. Choice C (monitoring vital signs) does not directly assess fatigue but rather general health status. Choice D (monitoring hemoglobin and hematocrit values) can indicate anemia but may not fully capture the patient's fatigue experience.
Question 7 of 9
A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling make his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client’s concern?
Correct Answer: B
Rationale: The correct answer is B: Disturbed body image. The client's concern about the external fixation device making his leg look ugly indicates a disturbance in his perception of his own body image. This diagnosis focuses on the client's feelings and emotions related to his appearance, which can impact his self-esteem and psychological well-being. Rationale: 1. Impaired physical mobility (A) is not the most appropriate diagnosis in this scenario as the client's concern is related to the appearance of his leg, not his ability to move. 2. Risk for infection (C) is not the best choice because the client's concern is not directly related to the risk of infection but rather to the aesthetic aspect of his leg. 3. Risk for social isolation (D) is not the most suitable diagnosis as the client's concern is more about his own perception of his appearance rather than the potential impact on his social interactions.
Question 8 of 9
The nurse is preparing to administer a unit of blood to a client’s who’s anemic. After its removal from the refrigerator, the blood should be administered within:
Correct Answer: C
Rationale: The correct answer is C: 2 hours. Blood should be administered within 30 minutes to 4 hours after removal from the refrigerator to prevent bacterial growth and maintain its efficacy. Option C falls within this timeframe, ensuring safety and effectiveness. Option A (1 hour) is too short, while option B (4 hours) and option D (6 hours) exceed the recommended timeframe, increasing the risk of bacterial contamination and compromising the quality of the blood product.
Question 9 of 9
A client asks nurse Carlos the rationale for giving multi-drug treatment for tuberculosis. Which is an appropriate response?
Correct Answer: D
Rationale: The correct answer is D because using multiple drugs for tuberculosis reduces the development of resistant strains of the bacteria. When multiple drugs are used simultaneously, it decreases the likelihood of the bacteria developing resistance to any single drug. This approach helps to ensure that the treatment remains effective over time. Explanation for other choices: A: While using multiple drugs may allow for reduced dosages, the primary rationale is not solely to administer lower levels of drugs. B: Although using multiple drugs may help in managing side effects, the primary rationale is to prevent the development of resistant strains. C: While multiple drugs may have a synergistic effect, the main purpose is to prevent resistance rather than potentiate the action of individual drugs.