ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 9
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Correct Answer: A
Rationale: The correct answer is A: Completes a comprehensive database. In the first phase of the nursing process (assessment), the nurse collects data to form a comprehensive database about the patient's health status. This step is crucial as it provides the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities of patient care (C) is part of the third phase (planning), and determining whether outcomes have been achieved (D) is in the fourth phase (evaluation). Completing a comprehensive database in the first phase ensures a thorough understanding of the patient's needs before proceeding to the next steps in the nursing process.
Question 2 of 9
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 3 of 9
The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct: 1. Having intercourse with just the spouse means a monogamous relationship with a trusted partner, minimizing risk of exposure to HIV. 2. It eliminates the risk of contracting HIV from multiple sexual partners. 3. This choice adheres to safer sex practices by reducing the chances of exposure to HIV. 4. This choice also promotes trust and communication within the relationship, further reducing the risk of HIV transmission. Summary: - Choice A is correct as it promotes monogamy and reduces the risk of exposure to HIV. - Choices B, C, and D do not guarantee zero risk of HIV transmission as blood donations, HIV antibodies, and condom use can still pose risks if not used or implemented correctly.
Question 4 of 9
Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
Correct Answer: A
Rationale: Step 1: Orthopnea is a classic symptom of congestive heart failure (CHF) due to fluid accumulation in the lungs when lying flat. Step 2: This symptom occurs because when lying down, the fluid redistributes, making it harder to breathe. Step 3: Fever (choice B) is not typically associated with CHF unless there is an underlying infection. Step 4: Weight loss (choice C) is more indicative of conditions like cancer or malnutrition, not CHF. Step 5: Calf pain (choice D) is more commonly associated with deep vein thrombosis, not CHF. Summary: Orthopnea is the best assessment finding indicating CHF, while the other choices are more likely related to different health conditions.
Question 5 of 9
A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
Correct Answer: D
Rationale: The correct answer is D. First, the nurse should put the implant back in place using forceps and a shield for self-protection. This is important to limit the exposure to radiation for both the client and the nurse. Second, the nurse should call for help to ensure proper handling and further assistance. Standing away from the implant (choice A) does not address the immediate need to secure the implant. Picking up the implant with long-handled forceps and placing it in a lead-lined container (choice B) should only be done by trained personnel to prevent further exposure. Leaving the room and notifying the radiation therapy department immediately (choice C) delays the immediate action needed to prevent unnecessary radiation exposure.
Question 6 of 9
The nurse is caring for a patient with HIV who has diarrhea. Which of the following would be most therapeutic to teach the patient to avoid in the diet to reduce diarrhea?
Correct Answer: C
Rationale: The correct answer is C: Raw fruits and vegetables. Patients with HIV and diarrhea should avoid raw fruits and vegetables due to their high fiber content, which can exacerbate diarrhea symptoms. Fiber can increase bowel movements and worsen diarrhea. Therefore, avoiding raw fruits and vegetables can help reduce diarrhea. Choice A (Potassium-rich food) is not the best answer because potassium-rich foods are important for patients with HIV to maintain electrolyte balance. Choice B (Liquid nutritional supplements) can actually be beneficial in providing essential nutrients to patients with HIV. Choice D (Frozen products) is not directly related to diarrhea management in patients with HIV.
Question 7 of 9
Which of the following intravenous solutions is hypotonic?
Correct Answer: C
Rationale: The correct answer is C: 0.45% saline. This solution is hypotonic because it has a lower osmolarity compared to the intracellular fluid. It contains fewer solutes than the cells, causing water to move into the cells by osmosis, potentially causing them to swell. Normal saline (A) and Ringer's lactate (B) are isotonic solutions, meaning they have a similar osmolarity to the intracellular fluid and do not cause significant water shifts. 5% dextrose in normal saline (D) is a hypertonic solution, containing more solutes than the cells, leading to water movement out of the cells.
Question 8 of 9
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
Correct Answer: A
Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully. Choice B may overwhelm the patient, Choice C disrupts the communication process, and Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.
Question 9 of 9
Which of the following lab value profiles should the nurse know to be consistent with hemolytic anemia?
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer (A): 1. Increased RBC: Hemolytic anemia leads to increased RBC production as the body compensates for the destruction of red blood cells. 2. Decreased bilirubin: Bilirubin levels decrease due to the accelerated breakdown of red blood cells. 3. Decreased Hgb and Hct: Hemolysis causes a decrease in hemoglobin and hematocrit levels as red blood cells are destroyed. 4. Increased reticulocytes: Reticulocytes are immature red blood cells released by the bone marrow in response to increased RBC destruction. Summary: - Choice B is incorrect as hemolytic anemia would lead to increased, not decreased, bilirubin levels. - Choice C is incorrect as hemolytic anemia would lead to decreased, not increased, Hgb and Hct levels. - Choice D is incorrect as hemolytic anemia would not lead to increased levels of all parameters