ATI RN
Nursing Process Exam Questions Questions
Question 1 of 5
The nurse has been asked to prepare an intervention plan for a client, age 70, admitted for treatment of renal calculi. He complains of frequent pain due to increased pressure in the renal pelvis and is frightened of the excruciating pain. Which of the ff measures can the nurse include in the client’s nursing care plan? Choose all that apply
Correct Answer: B
Rationale: The correct answer is B: Encourage ambulation and liberal fluid. Encouraging ambulation can help in the movement of kidney stones and alleviate pain. Liberal fluid intake helps in flushing out kidney stones and preventing further stone formation. Incorrect options: A: Administering prescribed nephrotoxic drugs can worsen kidney function and exacerbate the pain. C: Observing aseptic principles when changing intake is important for infection prevention but not directly related to pain management for renal calculi. D: Providing a comfortable position can offer temporary relief but does not address the underlying cause of kidney stone pain.
Question 2 of 5
A patient with abnormal sodium losses is receiving a house diet. To provide 1,600mg sodium daily, the nurse could supplement the patient’s diet with:
Correct Answer: D
Rationale: The correct answer is D because 1 beef cube contains about 1,000mg of sodium. To reach 1,600mg, the patient needs an additional 600mg. 12oz of tomato juice contains approximately 600mg of sodium, making it the right choice. A: Not enough sodium from the beef cube and tomato juice. B: Too much sodium from the 16oz of tomato juice. C: Too much sodium from the 4 beef cubes.
Question 3 of 5
Ms. CC’s laboratory values indicate hemoconcentration secondary to fluid loss. Which of the following intravenous solutions would be most appropriate during initial fluid replacement therapy?
Correct Answer: C
Rationale: The correct answer is C: 5% dextrose and water with 60 mEq. This solution is appropriate because it provides both fluid replacement (water) and electrolyte replacement (60 mEq). The dextrose helps prevent hypoglycemia. Choice A is incorrect as 10% dextrose and saline may worsen hemoconcentration. Choice B is not ideal as 5% dextrose and water lacks electrolytes needed for fluid balance. Choice D, distilled water with KCl, is dangerous as it lacks dextrose and may lead to electrolyte imbalances.
Question 4 of 5
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
Correct Answer: A
Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow. Incorrect choices: B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties. C: James’ neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties. D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.
Question 5 of 5
An elderly nursing home resident who has always been alert and oriented is now showing signs of dehydration and has become confused. Which electrolyte imbalance is most likely involved?
Correct Answer: D
Rationale: The correct answer is D: Hypomagnesemia. Dehydration can lead to electrolyte imbalances, and hypomagnesemia can cause confusion in elderly patients. Magnesium plays a crucial role in brain function and its deficiency can result in cognitive impairment. Hyponatremia (A) typically presents with symptoms like weakness and confusion but not necessarily dehydration. Hypercalcemia (B) and hyperkalemia (C) are less likely to cause confusion in this scenario. Therefore, hypomagnesemia is the most likely electrolyte imbalance involved in the elderly nursing home resident's confusion.