Questions 9

ATI RN

ATI RN Test Bank

Nursing Process NCLEX Questions Questions

Question 1 of 5

The nurse is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse plan to use to dilute this medication?

Correct Answer: C

Rationale: The correct answer is C: Normal saline solution. Phenytoin is incompatible with dextrose solutions, so options A and D are incorrect. Lactated Ringer's solution contains calcium, which can interact with phenytoin, leading to precipitation. Therefore, option B is also incorrect. Normal saline is the most compatible diluent for phenytoin, maintaining the drug's stability and effectiveness. It is essential to use the appropriate diluent to prevent adverse reactions or drug interactions.

Question 2 of 5

At health fair, an oncology nurse answers questions about risk factors for various types of cancer. One person with a family history of colon cancer asks the nurse to identify risk factors for this type of cancer. The nurse should identify:

Correct Answer: B

Rationale: The correct answer is B: Obesity. Obesity is a known risk factor for colon cancer as excess body fat, especially around the waist, can lead to inflammation and insulin resistance, increasing the likelihood of cancerous cell growth in the colon. Smoking (choice A) is more strongly associated with lung and other types of cancer, not specifically colon cancer. Heavy alcohol consumption (choice C) is linked to other types of cancer, such as liver and esophageal cancer, but not as strongly to colon cancer. Saccharin consumption (choice D) has not been definitively linked to an increased risk of colon cancer.

Question 3 of 5

A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A: Anxiety related to barium enema. This is the correct choice because nursing diagnoses should focus on the patient's actual or potential health problems, not just medical conditions. Anxiety is a common response to medical procedures like a barium enema. It is essential for the nurse to address the patient's emotional and psychological needs. Summary: B: Impaired gas exchange related to asthma is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on the patient's response to the medical condition. C: Impaired physical mobility related to incisional pain is a potential nursing diagnosis, but the focus should be on the patient's response to the pain, not just the pain itself. D: Nausea related to adverse effect of cancer medication is also a medical diagnosis. Nursing diagnoses should address the patient's response to the medication side effects, not just the side effects themselves.

Question 4 of 5

A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)

Correct Answer: C

Rationale: The correct answer is C because Nursing Outcomes Classification adds objectivity to judging a patient's progress by providing standardized criteria for assessing outcomes. This helps in evaluating the effectiveness of interventions and tracking improvements accurately. Other choices are incorrect: A is wrong because Nursing Outcomes Classification includes 7 domains but not necessarily for level 1; B is incorrect as it uses a 5-point Likert scale, not a 3-point scale; and D is inaccurate because Nursing Outcomes Classification guides the selection of interventions based on the identified outcomes, not allowing complete freedom in choosing interventions.

Question 5 of 5

Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?

Correct Answer: B

Rationale: Step-by-step rationale for choice B: Footboard and splint: 1. Footboard helps prevent foot drop by maintaining proper alignment and preventing pressure ulcers. 2. Splint helps stabilize and support Franco's limbs to prevent contractures and maintain proper positioning. 3. Both items are essential for Franco's safety, comfort, and prevention of complications. 4. Hand bell and extra bed linen (Choice A) are not crucial for Franco's immediate care needs. 5. Sandbag and trochanter rolls (Choice C) are not directly relevant to Franco's specific conditions. 6. Suction machine and gloves (Choice D) are important for airway management but not the priority for bedside equipment in this case.

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