ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
The nurse knows which of the following is true about immunity?
Correct Answer: C
Rationale: Rationale for Answer C: Antibodies are produced by the B-cells. B-cells are a type of lymphocyte that differentiate into plasma cells, which are responsible for producing antibodies in response to antigens. This process is a key component of the humoral immune response. Therefore, the statement that antibodies are produced by the B-cells is true. Summary of Incorrect Choices: A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity. B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. D: Lymphocytes increasing with an allergic response is not directly related to the production of antibodies by B-cells. Allergic responses involve a different mechanism.
Question 2 of 5
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 3 of 5
A client diagnosed with systemic lupus erythematosus (SLE) comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone daily. When adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?
Correct Answer: C
Rationale: The correct answer is C: Osteoporosis. Long-term corticosteroid therapy, such as prednisone, is known to cause bone loss and increase the risk of osteoporosis. Corticosteroids inhibit bone formation and increase bone resorption, leading to decreased bone density and increased fracture risk, which can manifest as severe back pain. Incorrect choices: A: Hypertension - Corticosteroids can cause fluid retention and sodium retention, leading to hypertension, but it is not typically associated with severe back pain. B: Muscle wasting - Corticosteroids can lead to muscle weakness, but severe back pain is not typically related to muscle wasting. D: Truncal obesity - Corticosteroids can cause weight gain, especially in the trunk area, but this is not directly responsible for severe back pain.
Question 4 of 5
Which of the ff nursing interventions is essential for a client during the Schilling test?
Correct Answer: A
Rationale: The correct answer is A because collecting urine 24-48 hrs after the client has received nonradioactive B12 is essential for the Schilling test to evaluate vitamin B12 absorption. Urine is collected to measure the excretion of radioactive B12, which helps in diagnosing pernicious anemia or malabsorption issues. Incorrect choices: B: Collecting blood samples is not necessary for the Schilling test as it primarily involves urine collection. C: Allowing oral fluid consumption is important to prevent dehydration and is not contraindicated after receiving nonradioactive B12. D: Making the client lie down in the supine position is unnecessary for the Schilling test and may not affect the test results.
Question 5 of 5
A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate of 8 breaths/min. Morphine is an opioid that can cause respiratory depression as a side effect. A respiratory rate of 8 breaths/min indicates hypoventilation, which is a potential adverse effect of morphine. This is a critical finding that requires immediate intervention to prevent respiratory failure or arrest. A: Voiding of 350mL of concentrated urine in 8 hours is not directly related to morphine's adverse effects. Morphine can cause urinary retention, not increased voiding. C: Irregular heart rate of 82 beats/min is within normal range and not a typical adverse effect of morphine. Morphine can cause bradycardia or tachycardia, but not irregular heart rate specifically. D: Pupils constricted and equal is a common side effect of morphine due to its effect on the central nervous system. This finding does not suggest an adverse effect; it is an expected pharmac
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