ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 9
The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?
Correct Answer: A
Rationale: The correct answer is A: Universal blood and body fluid precautions. This is recommended by the CDC to prevent the spread of HIV because the virus can be present in blood and certain body fluids. Universal precautions involve treating all blood and body fluids as potentially infectious. Incorrect choices: B: Body systems isolation - This is not specific to preventing the spread of HIV and is not recommended by the CDC. C: Laminar flow room during active infection - This is not a standard recommendation for preventing the spread of HIV. D: Needle and syringe precautions - While important in preventing needlestick injuries, it is not the primary method recommended by the CDC for preventing the spread of HIV.
Question 2 of 9
A client is hospitalized with oat cell carcinoma of the lung. To manage severe pain, the physician prescribes a continuous I.V. infusion of morphine. Which formula should the nurse use to check that the morphine dose is appropriate for the client?
Correct Answer: C
Rationale: The correct formula to calculate the appropriate morphine dose for the client is 5 mg/kg of body weight. This is the most suitable formula because morphine dosing is typically based on weight to ensure appropriate pain management and to prevent adverse effects. By using this formula, the nurse can calculate the exact dose based on the client's weight, providing personalized care. Choice A (1 mg/kg of body weight) is too low of a dose and may not effectively manage severe pain. Choice B (5 mg/70kg of body weight) is not ideal as it does not account for variations in weight among individuals. Choice D (10mg/70kg of body weight) would result in an overdose for most patients, potentially causing serious harm. Therefore, by using the formula of 5 mg/kg of body weight, the nurse can ensure that the morphine dose is appropriate and safe for the client.
Question 3 of 9
The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
Correct Answer: D
Rationale: The correct answer is D: To establish a database to identify problems and strengths. This initial assessment is crucial for gathering comprehensive information about the client's health status, including past medical history, current health problems, and potential risk factors. By establishing a database, the nurse can identify both existing health issues that need to be addressed and strengths that can be built upon for effective care planning. This assessment serves as the foundation for developing an individualized care plan and monitoring the client's progress throughout their hospital stay. Explanation of other options: A: To gather data about a specific and current health problem - While this may be part of the assessment process, the main purpose is broader in scope to establish a comprehensive database. B: To identify life-threatening problems that require immediate attention - While identifying urgent issues is important, the initial assessment is not solely focused on life-threatening problems. C: To compare and contrast current health status to baseline data - While comparing to baseline data is important for tracking changes, the primary purpose
Question 4 of 9
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
Correct Answer: C
Rationale: After a transsphenoidal adenohypophysectomy, hormone replacement therapy is needed due to the removal of the pituitary gland. This surgery is typically done to treat pituitary carcinoma, making choice C the correct answer. Pituitary carcinoma is a type of cancer that affects the pituitary gland. Choices A, B, and D are incorrect because they do not involve the pituitary gland. Esophageal carcinoma affects the esophagus, laryngeal carcinoma affects the larynx, and colorectal carcinoma affects the colon and rectum. Therefore, the correct choice, C, is the only one related to the pituitary gland and the procedure described.
Question 5 of 9
The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
Correct Answer: B
Rationale: The correct answer is B because the patient being able to ambulate in the hallway with crutches indicates that the expected outcome of improved physical mobility due to the fractured leg has been met. This demonstrates progress towards independence and recovery. A is incorrect because the patient still requires assistance, indicating dependency. C is incorrect because denial of pain does not necessarily indicate improved physical mobility. D is incorrect because it is too general and does not directly show achievement of the specific goal related to physical mobility.
Question 6 of 9
A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?
Correct Answer: D
Rationale: The correct answer is D: Involve the son in the plan of care as much as possible. This is important for several reasons. Firstly, involving the son promotes family-centered care, which can improve patient outcomes. Secondly, the son may provide valuable insights into the patient's preferences and needs. Thirdly, it can help reduce the patient's confusion by providing familiar support. Option A is incorrect as it disregards the potential benefits of involving family members. Option B is incorrect as it focuses on the patient's rest without considering the emotional support the son may provide. Option C is incorrect as it assumes the gender of the family member matters more than their relationship to the patient.
Question 7 of 9
A patient is being given penicillin via IV piggyback and develops an anaphylactic reaction. Which of the following should be the nurse’s first action?
Correct Answer: D
Rationale: The correct answer is D: Turn off the antibiotic. This should be the nurse's first action because in an anaphylactic reaction, stopping the administration of the causative agent is crucial to prevent further harm. Continuing the antibiotic (Choice B) can worsen the reaction. Calling the doctor (Choice A) may cause a delay in the immediate intervention needed. Calling for help (Choice C) is important but turning off the antibiotic takes precedence to stop the allergen.
Question 8 of 9
An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?
Correct Answer: C
Rationale: Upon arrival, checking the lungs for equal breath sounds bilaterally is the first action. This is crucial to assess airway patency and breathing effectiveness in a patient with a history of diving accident and intubation. Ensuring proper oxygenation takes precedence over other actions. Taking vital signs, inserting an IV line, and performing a neurologic check can wait until airway and breathing are adequately assessed.
Question 9 of 9
As part of primary cancer prevention program, an oncology nurse answers questions from the public at health fair. When someone asks about the laryngeal cancer, the nurse should explain that:
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Laryngeal cancer is strongly linked to smoking and alcohol consumption. 2. Both smoking and alcohol use are modifiable risk factors, meaning they can be prevented. 3. By avoiding smoking and excessive alcohol intake, individuals can significantly reduce their risk of developing laryngeal cancer. 4. Therefore, laryngeal cancer is considered one of the most preventable types of cancer. Summary of why the other choices are incorrect: B. Inhaling polluted air can be a risk factor for laryngeal cancer, so this statement is inaccurate. C. Laryngeal cancer occurs more frequently in men than women, so this statement is incorrect. D. Squamous cell carcinoma, not adenocarcinoma, is the most common type of laryngeal cancer, making this statement incorrect.