ATI RN
Nursing Process Questions Questions
Question 1 of 9
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
Correct Answer: C
Rationale: Objective data in nursing refers to measurable and observable information. Respirations at 16 per minute are a specific, quantifiable measurement that the nurse can directly observe, making it objective data. This information is vital for assessing the patient's respiratory status accurately. Choice A is incorrect because stating "doesn't feel good" is a subjective statement based on the patient's perception and cannot be directly measured or observed. Choice B, reporting a headache, is also subjective as it relies on the patient's description of their symptoms. Choice D, being nauseated, is subjective as well, as it is a symptom reported by the patient and not a quantifiable measurement. In summary, choice C is correct as it represents objective data due to its quantifiable and observable nature, while the other choices are subjective and based on the patient's perceptions or feelings.
Question 2 of 9
A patient has orders to receive 1 L (1000 mL) of 5% dextrose and lactated Ringer’s solution to be infused over 8 hours. How many millilitres will be infused per hour?
Correct Answer: C
Rationale: The correct answer is C: 125 mL/h. To calculate the infusion rate per hour, we divide the total volume (1000 mL) by the total time in hours (8 hours). 1000 mL / 8 hours = 125 mL/h. This ensures a consistent and accurate infusion rate throughout the 8-hour period. Choice A (80 mL/h) is incorrect because it underestimates the infusion rate. Choice B (100 mL/h) is incorrect because it does not divide the total volume by the total time correctly. Choice D (150 mL/h) is incorrect because it overestimates the infusion rate.
Question 3 of 9
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, leading to impaired gas exchange. The nurse correctly identified the underlying respiratory issue. A: Ineffective breathing pattern related to pneumonia is incorrect as it focuses on the pattern of breathing rather than the physiological problem causing the breathing difficulty. B: Risk for infection related to chest x-ray procedure is incorrect as the patient already has a diagnosis of pneumonia, so the focus should be on managing the existing condition. C: Risk for deficient fluid volume related to dehydration is incorrect as there is no indication of dehydration in the question stem. In summary, the nurse's diagnosis of Impaired gas exchange related to alveolar-capillary membrane changes is the most appropriate as it addresses the respiratory issue caused by pneumonia and lower lobe infiltrates.
Question 4 of 9
Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
Correct Answer: C
Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease. Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites. Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites. Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.
Question 5 of 9
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
Correct Answer: C
Rationale: The correct answer is C because respiratory rate is an observable and measurable data point, making it objective. Objective data is factual and observable, such as vital signs. Choices A, B, and D are subjective data as they rely on the patient's perception or interpretation, which can be influenced by various factors and may not always be accurate or reliable. In this case, the nurse can directly measure and document the patient's respiratory rate, making it an objective piece of information.
Question 6 of 9
A client diagnosed with DIC is ordered heparin. What is the reason for this medication?
Correct Answer: A
Rationale: The correct answer is A: Prevent clot formation. Heparin is an anticoagulant that inhibits the formation of blood clots. In DIC (Disseminated Intravascular Coagulation), there is excessive clotting throughout the body, leading to organ damage. By administering heparin, we aim to prevent further clot formation and reduce the risk of complications. Choice B is incorrect because heparin does not increase clot formation; it works to inhibit clotting. Choice C is incorrect as heparin does not directly increase blood flow to target organs. Choice D is also incorrect as heparin does not decrease blood flow to target organs; its primary role is anticoagulation.
Question 7 of 9
A client is admitted to an acute care facility with a myocardial infarction. During the admission history, the nurse learns that the client also has hypertension and progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity. Myocardial infarction, hypertension, and progressive systemic sclerosis can lead to impaired circulation and skin breakdown. Clients with these conditions are at risk for pressure ulcers due to decreased blood flow and compromised skin integrity. The other options, B: Imbalanced nutrition, C: Constipation, and D: Ineffective thermoregulation, do not directly relate to the client's conditions or the potential complications associated with them. Therefore, the most appropriate nursing diagnosis for this client would be A: Risk for impaired skin integrity.
Question 8 of 9
A nurse who is caring for an unresponsive client formulates the nursing diagnosis, 'Risk for Aspiration related to reduced level of consciousness.' The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
Correct Answer: A
Rationale: The correct answer is A because a nursing diagnosis typically consists of two parts: the problem (Risk for Aspiration) and the related factor (reduced level of consciousness). This format helps clearly identify the client's health issue and its cause. Choice B is incorrect as it refers to a nursing diagnosis focusing on the client's response. Choice C is incorrect as it describes an outcome, not a diagnosis. Choice D is incorrect as a nursing diagnosis should be based on evidence, not made without support. Therefore, the correct choice is A due to the structure and clarity it provides in identifying the client's risk.
Question 9 of 9
The spouse of a client with gastric cancer expresses concern that the couple’s children may develop this type of cancer when they’re older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
Correct Answer: A
Rationale: Step 1: Type A blood has been associated with a slightly higher risk of developing gastric cancer compared to other blood types. Step 2: The nurse mentioned a 10% increase in risk, which aligns with the increased risk associated with Type A blood. Step 3: Type AB and Type B blood do not have the same increased risk for gastric cancer as Type A blood. Step 4: Type O blood is actually associated with a lower risk of gastric cancer compared to Type A blood. Step 5: Therefore, the correct answer is A: Type A blood.