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 are measurable and observable facts. Respirations (C) of 16 per minute is objective data as it is a quantifiable measurement that can be counted and recorded. It is not influenced by personal interpretation or bias. Choices A, B, and D are subjective data as they rely on the patient's feelings, perceptions, or symptoms, which can vary and are open to interpretation. Therefore, choice C is the correct answer as it represents concrete, verifiable information that can be used in the patient's assessment and care planning.
Question 2 of 9
A client has undergone the Snellen eye chart test and has 20/40 vision. Which of the ff is true for this client?
Correct Answer: A
Rationale: The correct answer is A. In the Snellen eye chart test, the first number (20) represents the distance at which the client is viewing the chart, and the second number (40) represents the distance at which a person with normal vision can read the same line. Therefore, a client with 20/40 vision sees letters at 20 feet that others with normal vision can read at 40 feet. Choices B, C, and D are incorrect because they do not accurately reflect the interpretation of the 20/40 vision result from the Snellen eye chart test. B is incorrect because the client does not see letters at 40 feet that others can read at 20 feet. Choices C and D are incorrect because the Snellen eye chart test measures visual acuity, not color perception.
Question 3 of 9
The patient is dangling at the bedside and states, “Oh, my stomach is tearing open.” Which of the following actions should the nurse immediately take when dehiscence occurs?
Correct Answer: B
Rationale: The correct answer is B: Have patient lie down. When a patient experiences dehiscence (surgical wound separation), lying down helps reduce tension on the wound, minimizing the risk of further tearing. This position also allows the nurse to assess the wound properly. Choice A is incorrect because sitting upright can increase intra-abdominal pressure, worsening the dehiscence. Choice C is incorrect as slowing IV fluids is not a priority in managing dehiscence. Choice D is incorrect because obtaining a sterile suture set should only be done by a healthcare provider and is not the immediate action needed for dehiscence.
Question 4 of 9
Which of the following outcomes would indicate successful treatment of diabetes insipidus?
Correct Answer: A
Rationale: The correct answer is A because successful treatment of diabetes insipidus aims to reduce excessive urine output and dehydration. A fluid intake of less than 2,500mL in 24 hours indicates proper control of fluid balance. Choice B is incorrect because urine output of more than 200mL/hour suggests ongoing excessive fluid loss, which is not indicative of successful treatment. Choice C is incorrect as a blood pressure of 90/50mmHg is low and may indicate hypotension, which is not a specific indicator of successful diabetes insipidus treatment. Choice D is incorrect because a pulse rate of 126 beats/min is not a direct marker of diabetes insipidus treatment success. In summary, the correct indicator of successful treatment of diabetes insipidus is a reduction in fluid intake, option A, as it signifies improved fluid balance and hydration status.
Question 5 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 as it directly addresses the underlying physiological issue of impaired gas exchange due to alveolar-capillary membrane changes. The infiltrates indicate infection and inflammation in the lower lobes, leading to difficulty in oxygen and carbon dioxide exchange. This diagnosis aligns with the patient's medical condition and helps guide nursing interventions focused on improving oxygenation. Choice A is incorrect because ineffective breathing pattern is a broad diagnosis that does not specifically address the gas exchange issue seen in pneumonia. Choice B is incorrect as the risk for infection is already present with the diagnosis of pneumonia and does not directly address the patient's current respiratory status. Choice C is incorrect as dehydration is not the primary concern in a patient with pneumonia and lower lobe infiltrates.
Question 6 of 9
Which of the following conditions is suspected?
Correct Answer: A
Rationale: The correct answer is A: Anemia. Anemia is a common condition characterized by a decrease in red blood cells or hemoglobin levels, leading to symptoms like fatigue and weakness. It is often suspected based on symptoms such as pale skin and shortness of breath. Rheumatic arthritis (B) is a type of arthritis affecting joints, not related to the blood. Leukemia (C) is a type of cancer affecting the blood and bone marrow. Systemic Lupus Erythematosus (SLE) (D) is an autoimmune disease that can affect various organs, not specifically related to blood cell levels. Therefore, based on the symptoms described, anemia is the most likely condition to be suspected.
Question 7 of 9
Which of the following explanations by the nurse will help a patient understand what to expect during a bronchoscopy?
Correct Answer: A
Rationale: The correct answer is A because it accurately describes the procedure of bronchoscopy. The nurse's explanation should focus on the insertion of a small tube through the nose or mouth into the bronchi to visualize the airways. This information helps the patient understand the basic process and what to expect during the procedure. Choice B is incorrect as bronchoscopy does not involve breathing a radioactive substance to show diseased areas in the lungs. Choice C is also incorrect as there is no requirement to drink a thick white liquid for bronchoscopy. Choice D is incorrect as dye injection is not a standard part of bronchoscopy, and asking about allergies to dye is irrelevant in this context.
Question 8 of 9
Nurse Carlos teaches a community adult class about the common symptoms of tuberculosis. Which of the following should Nurse Carlos include?
Correct Answer: A
Rationale: The correct answer is A: weight loss. Weight loss is a common symptom of tuberculosis due to the impact of the infection on the body's metabolism and appetite. This symptom is important to recognize as it can be an early indicator of the disease. Dyspnea on exertion (B) is not a common symptom of tuberculosis, as it typically affects the lungs rather than causing difficulty breathing. Increased appetite (C) is not a typical symptom, as TB usually leads to decreased appetite and weight loss. Mental status changes (D) are not directly associated with tuberculosis and are more commonly seen in other conditions affecting the brain. Therefore, weight loss is the most relevant symptom to include in the teaching material for identifying possible cases of tuberculosis.
Question 9 of 9
The nurse is working in a support group for client with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
Correct Answer: C
Rationale: Rationale: Choice C is the correct answer because following safer-sex practices is crucial in preventing the spread of HIV/AIDS. By emphasizing this point, the nurse can educate clients on reducing the risk of transmission. Safer-sex practices include using condoms and practicing monogamy. Choice A is incorrect because avoiding recreational drugs and alcohol, while important for overall health, is not directly related to preventing the spread of HIV/AIDS. Choice B is incorrect as it is essential for individuals to inform their sexual partners about their HIV status to prevent transmission and ensure informed consent. Choice D is incorrect because while it may be required by law in some places, it is not the most crucial point for preventing the spread of HIV/AIDS within a support group setting.