ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 9
The nurse is caring for a patient with a bowel resection. Which of the following would indicate that the patient’s gastrointestinal tract is resuming normal function?
Correct Answer: B
Rationale: The correct answer is B: Presence of flatus. This indicates normal gastrointestinal function post-bowel resection. Flatus production signifies peristalsis and passage of gas through the intestines, indicating that the bowels are working. A, firm abdomen, may indicate distention or ileus, not normal function. C, excessive thirst, is unrelated to bowel function. D, absent bowel sounds, may indicate ileus or bowel obstruction, not normal function.
Question 2 of 9
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. Safety first: Patient safety is the top priority in healthcare. Vital signs provide crucial information about the patient's condition. 2. Accountability: The nurse is responsible for ensuring accurate vital sign documentation. Asking the NAP to record vital signs before medication administration ensures accountability. 3. Communication: Clear communication between healthcare team members is essential to provide quality care. Asking the NAP to record vital signs promotes effective communication. Summary of Incorrect Choices: A (abnormal vital signs): Administering medications without knowing the patient's vital signs, especially if abnormal, can be dangerous and potentially harmful. B (review upon return): Delaying vital sign assessment until later can lead to missed opportunities for timely intervention if the patient's condition changes. D (omit vital signs): Neglecting vital signs based on assumption risks overlooking potential issues that could impact patient care and outcomes.
Question 3 of 9
Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
Correct Answer: B
Rationale: The correct answer is B: Acute pain. This is the only choice that aligns with NANDA-I approved nursing diagnoses. Acute pain is a common nursing diagnosis that focuses on addressing a patient's immediate discomfort. NANDA-I emphasizes the importance of using standardized nursing diagnoses to improve communication and ensure proper interventions. Sore throat (A) and sleep apnea (C) are symptoms or medical diagnoses, not specific nursing diagnoses. Heart failure (D) is a medical diagnosis and not a NANDA-I approved nursing diagnosis.
Question 4 of 9
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
Correct Answer: A
Rationale: The correct answer is A: Cancerous lumps. Breast self-examination aims to detect any abnormal changes in the breasts, including potential cancerous lumps. Detecting cancerous lumps early increases the chances of successful treatment and improved outcomes. Choices B, C, and D are incorrect because while changes from previous self-examinations, areas of thickness or fullness, and fibrocystic masses can be important to note, the primary goal of breast self-examination is to identify any signs of breast cancer, such as cancerous lumps.
Question 5 of 9
A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Equipment. The nurse needs to ensure that necessary equipment is available to carry out interventions effectively and safely. Without the right equipment, the nurse may not be able to provide appropriate care. Safe environment (B) is important but not a resource that the nurse makes sure is available. Confidence (C) is a personal attribute and not a resource. Assistive personnel (D) are individuals who can help but are not resources that the nurse ensures are available.
Question 6 of 9
Which of the following client outcomes best describes the parameters for achieving the outcome?
Correct Answer: B
Rationale: The correct answer is B because it provides specific, measurable, achievable, relevant, and time-bound (SMART) parameters for achieving the outcome. It outlines the calorie intake, meal frequency, and start date, which allows for clear monitoring and evaluation of progress. Choice A is too vague and lacks specificity. Choice C focuses on wound care, not dietary goals. Choice D lacks specificity and a timeframe, making it difficult to measure success. In conclusion, choice B is the best option as it aligns with effective goal-setting principles.
Question 7 of 9
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Alteration in tissue perfusion related to bleeding and diminished blood flow. Disseminated intravascular coagulation (DIC) is a condition where blood clots form throughout the body, leading to both bleeding and clotting. This can result in decreased blood flow to tissues, causing tissue perfusion issues. Explanation: 1. Option A: Risk for increased cardiac output related to fluid volume excess is incorrect because DIC can lead to bleeding, causing a decrease in blood volume and potentially decreasing cardiac output. 2. Option B: Disturbed sensory perception related to bleeding into tissues is incorrect as DIC primarily affects blood clotting and bleeding, not sensory perception. 3. Option D: Risk for aspiration related to constriction of the respiratory musculature is incorrect as DIC does not directly cause constriction of respiratory muscles, but rather impacts the clotting and bleeding processes in the body. In summary, the correct answer is C because DIC can lead to altered tissue perfusion
Question 8 of 9
A client is undergoing a diagnostic work-up for suspected testicular cancer. When obtaining the client’s history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:
Correct Answer: D
Rationale: The correct answer is D: Cryptorchidism. Cryptorchidism, also known as undescended testicle, is a known risk factor for testicular cancer as the testicle does not descend into the scrotum during fetal development, increasing the risk of cancer development. Testosterone therapy during childhood (A) and early onset of puberty (B) are not directly linked to testicular cancer. Sexually transmitted diseases (C) typically do not increase the risk of testicular cancer. Therefore, choice D is the most relevant risk factor for testicular cancer in this scenario.
Question 9 of 9
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?
Correct Answer: A
Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. This is because soap can irritate the skin, leading to skin breakdown in a client at risk for impaired skin integrity due to radiation therapy. Avoiding soap helps to prevent further damage to the skin. Choice B is incorrect as talcum powder can further irritate the skin and should be avoided. Choice C is not relevant to preventing skin integrity issues. Choice D is incorrect because thoracic skin markings should not be removed as they are essential for accurate radiation delivery.