ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 9
The nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
Correct Answer: B
Rationale: The correct answer is B: The client wears a watch and wedding band. This is because metal objects such as watches and jewelry can be hazardous during an MRI scan due to the strong magnetic field, leading to potential movement or heating of the metal objects, causing harm to the client. A: The client lies still - This is important for obtaining clear images during an MRI scan and does not pose a threat to the client. C: The client asks questions - Asking questions during an MRI scan does not pose a direct threat to the client's safety. D: The client hears thumping sounds - Thumping sounds are a normal part of the MRI scan and do not pose a threat to the client's safety.
Question 2 of 9
Why should clients who take warfarin (Coumadin) refrain from food items such as green leafy vegetables and soybeans?
Correct Answer: A
Rationale: The correct answer is A because green leafy vegetables and soybeans are high in Vitamin K, which counteracts the anticoagulant effect of warfarin. Warfarin works by inhibiting Vitamin K-dependent clotting factors in the liver. By consuming Vitamin K-rich foods, the medication's effectiveness is reduced, leading to an increased risk of blood clot formation. Choices B, C, and D are incorrect because they do not address the specific interaction between Vitamin K and warfarin in affecting coagulation. Choice B suggests the opposite effect of what actually occurs. Choices C and D are irrelevant to the pharmacological mechanism of warfarin.
Question 3 of 9
When the nurse is reviewing a patient’s daily laboratory test results, which of the ff. electrolyte imbalances should the nurse recognize as predisposing the patient to digoxin toxicity?
Correct Answer: A
Rationale: Step-by-step rationale: 1. Digoxin toxicity can be potentiated by hypokalemia due to the risk of enhanced cardiac toxicity. 2. Hypokalemia can lead to increased sensitivity of cardiac cells to digoxin. 3. Low potassium levels can disrupt the sodium-potassium ATPase pump, enhancing digoxin's effects. 4. The nurse should recognize hypokalemia as a predisposing factor for digoxin toxicity. Summary: A: Hypokalemia is the correct answer as it enhances digoxin toxicity by affecting cardiac function. B: Hyponatremia does not directly predispose to digoxin toxicity. C: Hyperkalemia is not a predisposing factor and can actually counteract digoxin's effects. D: Hypernatremia is not directly related to digoxin toxicity.
Question 4 of 9
The nurse notes frequent muscle twitching when collecting admission data on a patient admitted for increasing muscle weakness. Which of the ff. terms should the nurse use to document this?
Correct Answer: A
Rationale: The correct answer is A: Fasciculations. Fasciculations are involuntary muscle twitches commonly seen with neurological conditions like motor neuron disease. In this case, the patient's muscle weakness and frequent muscle twitching indicate possible nerve damage. Chorea (B) is characterized by involuntary, jerky movements, not twitching. Atrophy (C) refers to muscle wasting, not twitching. Neuropathy (D) is a general term for nerve damage and does not specifically describe the muscle twitching seen in this patient.
Question 5 of 9
The nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
Correct Answer: B
Rationale: The correct answer is B: The client wears a watch and wedding band. This is because metal objects such as watches and jewelry can be hazardous during an MRI scan due to the strong magnetic field, leading to potential movement or heating of the metal objects, causing harm to the client. A: The client lies still - This is important for obtaining clear images during an MRI scan and does not pose a threat to the client. C: The client asks questions - Asking questions during an MRI scan does not pose a direct threat to the client's safety. D: The client hears thumping sounds - Thumping sounds are a normal part of the MRI scan and do not pose a threat to the client's safety.
Question 6 of 9
Blood cells are formed in the:
Correct Answer: C
Rationale: The correct answer is C: Bone marrow. Blood cells are primarily formed in the bone marrow through a process called hematopoiesis. The bone marrow contains stem cells that differentiate into various types of blood cells, including red blood cells, white blood cells, and platelets. Arterioles are small blood vessels that carry blood away from the heart, not involved in blood cell formation. Lymphoid tissue plays a role in immune function but not in blood cell production. Muscle tissue is primarily responsible for movement and does not have a role in blood cell formation. Therefore, the bone marrow is the correct answer as it is the main site of blood cell production in the body.
Question 7 of 9
Why should the nurse monitor angiotensin converting enzyme inhibitors cautiously in clients with renal or hepatic impairment and in older adults?
Correct Answer: B
Rationale: The correct answer is B: A sudden drop in BP may occur during the first 1-3 hours after the initial dose. Angiotensin converting enzyme inhibitors can cause vasodilation, leading to a reduction in blood pressure. In clients with renal or hepatic impairment and in older adults, these medications may not be cleared from the body as efficiently, increasing the risk of hypotension. Monitoring is crucial to prevent complications. Incorrect choices: A: A sudden raise in BP is unlikely with angiotensin converting enzyme inhibitors. C: Angiotensin converting enzyme inhibitors do not affect body temperature. D: Angiotensin converting enzyme inhibitors typically do not cause a sudden rise in pulse rate. In summary, monitoring for a potential drop in blood pressure is essential in vulnerable populations when using angiotensin converting enzyme inhibitors.
Question 8 of 9
A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
Correct Answer: D
Rationale: The correct answer is D, as exercise and a weight reduction diet are essential components in managing type 2 diabetes. Exercise helps lower blood glucose levels and improves insulin sensitivity. Weight reduction reduces insulin resistance. Choice A is incorrect because maintaining blood glucose levels between 180-200mg/dl is too high and can lead to complications. Choice B is incorrect as complete smoking cessation is crucial for overall health and diabetes management. Choice C is incorrect because eye examinations should be done annually, not every 2 years, to monitor for diabetic retinopathy. In summary, choice D is the best option as it directly addresses the management of type 2 diabetes.
Question 9 of 9
The nurse is aware that in communicating with an elderly client, the nurse will
Correct Answer: B
Rationale: The correct answer is B: Use a low-pitched voice. This is because elderly individuals often experience age-related hearing loss, especially in high frequencies. Using a low-pitched voice helps improve the clarity and understanding of communication. Incorrect choices: A: Leaning and shouting can be perceived as aggressive and disrespectful to the elderly client. C: Opening the mouth wide while talking does not enhance communication and might be seen as patronizing. D: Using a medium-pitched voice may still be difficult for the elderly client to hear clearly due to age-related hearing loss.