Questions 9

ATI RN

ATI RN Test Bank

Nursing Process 1 Test Questions Questions

Question 1 of 5

The nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?

Correct Answer: D

Rationale: The correct answer is D: Polyps. Polyps in the colon are precancerous growths that can develop into colorectal cancer over time. Identifying polyps during a medical history interview can raise suspicion for colorectal cancer due to their potential to progress into malignancy. Duodenal ulcer (A) is not directly related to colorectal cancer. Weight gain (B) is a non-specific symptom and does not specifically indicate colorectal cancer. Hemorrhoids (C) are common and usually benign, not directly linked to colorectal cancer.

Question 2 of 5

Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?

Correct Answer: A

Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank. Rationale: 1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway. 2. Oxygen tank: To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted. Summary of incorrect choices: B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy. C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation. D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.

Question 3 of 5

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client’s vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment?

Correct Answer: B

Rationale: The correct answer is B: Focused assessment. In this scenario, the nurse is continuously monitoring specific aspects such as vital signs, pupils, and orientation at regular intervals, which is characteristic of a focused assessment. This type of assessment allows the nurse to gather specific data related to the client's condition and respond promptly to any changes. A: Initial assessment is conducted upon admission to establish baseline data. C: Time-lapsed reassessment involves comparing current data to previous assessments over a longer period. D: Emergency assessment is performed in urgent situations to quickly identify life-threatening issues. By systematically assessing the client's vital signs, pupils, and orientation at frequent intervals, the nurse can provide timely and appropriate care in the intensive care unit setting.

Question 4 of 5

An adult has a central venous line. Which of the following should the nurse include in the plan of care?

Correct Answer: D

Rationale: The correct answer is D because monitoring for signs of infection, air embolus, and leakage/puncture are crucial in caring for a patient with a central venous line to prevent serious complications. Infections can lead to sepsis, air embolus can cause respiratory distress, and leakage/puncture can result in hemorrhage or damage to surrounding tissues. A: While a complete blood count and electrolytes may be important for monitoring the patient's overall health, they are not specific to the central venous line care. B: Regular chest x-rays are not necessary unless there are specific indications of line malposition or complications. C: Continuous infusion at a keep-vein-open rate is a standard practice but does not address the critical aspects of central line care mentioned in option D. Therefore, monitoring for signs of infection, air embolus, and leakage/puncture is the most essential component of the plan of care for a patient with a central venous line.

Question 5 of 5

24 hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:

Correct Answer: A

Rationale: The correct answer is A: Removal of the transplanted kidney. Hyperacute rejection is a severe and immediate immune response to the transplanted organ. In this case, the transplanted kidney must be removed promptly to prevent further complications, as it is irreversibly damaged. High-dose IV cyclosporine (B) is used for immunosuppression but is not effective in treating hyperacute rejection. Bone marrow transplant (C) is not indicated for kidney rejection. Intra-abdominal instillation of methylprednisolone sodium succinate (D) is used for acute rejection, not hyperacute rejection.

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