ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 9
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
Correct Answer: D
Rationale: The correct answer is D: Proper positioning. Proper positioning helps maintain joint alignment, prevents pressure ulcers, and reduces the risk of contractures by keeping the muscles in a neutral position. This is crucial in preventing complications associated with spasticity. A: Active exercise may exacerbate spasticity and lead to muscle fatigue, increasing the risk of contractures. B: Use of tilt board may not directly address the need for proper positioning to prevent contractures. C: Deep massage may provide temporary relief but does not address the underlying issue of maintaining proper positioning to prevent contractures.
Question 2 of 9
. A client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are only effective if the client:
Correct Answer: B
Rationale: Rationale: 1. Oral antidiabetic agents target insulin resistance, common in type 2 diabetes. 2. Type 1 diabetes lacks insulin production, making oral agents ineffective. 3. Choice A is incorrect as insulin cannot be taken orally. 4. Choice C is incorrect as oral agents are not indicated for type 2 diabetes. 5. Choice D is incorrect as pregnancy does not affect the type of diabetes.
Question 3 of 9
A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?
Correct Answer: B
Rationale: The correct answer is B because involving the client and family in developing outcomes promotes patient-centered care and increases the likelihood of achieving successful outcomes. This approach fosters collaboration, shared decision-making, and empowers the client and family in their own care. It also helps to ensure that the outcomes align with the client's values, preferences, and goals. Choices A, C, and D are incorrect because focusing solely on nursing goals without considering the client's perspective may lead to a lack of engagement and poor outcomes. Discouraging input from other healthcare providers limits the interdisciplinary approach to care, and focusing on why the nurse believes the outcome is important neglects the client's role in the decision-making process.
Question 4 of 9
A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heart burn. Which nursing instruction should the nurse provide?
Correct Answer: B
Rationale: The correct answer is B: "Take ferrous sulfate and the antacid at least 2 hours apart." Rationale: 1. Iron absorption is decreased in the presence of antacids due to decreased gastric acidity. 2. Antacids can bind to iron and reduce its absorption. 3. Taking them 2 hours apart allows for optimal iron absorption without interference from the antacid. 4. Taking them together (choice A) would decrease iron absorption. 5. Avoiding antacids altogether (choice C) may not be necessary if spaced apart appropriately. 6. Taking them 1 hour apart (choice D) may still lead to decreased iron absorption due to antacid interference.
Question 5 of 9
The nurse is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make?
Correct Answer: A
Rationale: The correct answer is A because testicular cancer is indeed a highly curable type of cancer if detected early through self-examinations. This empowers the client to take control of their health. Choice B is incorrect as testicular cancer is detectable through self-examinations. Choice C is incorrect as testicular cancer is not the number one cause of cancer deaths in males; it is relatively rare. Choice D is incorrect as testicular cancer is more common in younger men, typically between the ages of 15 and 44.
Question 6 of 9
A 23 y.o. woman is seen at an outpatient clinic for a routine Pap smear. When questioned, she states she is deciding whether to engage in sexual activity with a man she is just getting to know. She asks how she can tell if he has an STD. Which response by the nurse is best?
Correct Answer: D
Rationale: Step 1: The correct answer is D because it emphasizes the importance of medical examination and diagnostic testing to determine if the man has an STD. Step 2: Visual inspection (choice B) is not reliable as some STDs may not present with visible symptoms. Step 3: Relying solely on appearance and condom use (choices A and C) does not guarantee protection against all STDs. Step 4: Choice D is the best option as it advocates for seeking professional medical advice for accurate diagnosis and treatment.
Question 7 of 9
A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A. The most appropriate outcome for the nurse to include in the plan of care is for the patient to have one soft, formed bowel movement by the end of the shift. This outcome directly addresses the nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. By aiming for a soft, formed bowel movement, the nurse is working towards alleviating the constipation issue caused by the pain medications. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART), making it an appropriate goal for the patient's care plan. Choice B is incorrect because walking unassisted to the bathroom does not directly address the constipation issue. Choice C is incorrect as offering laxatives or stool softeners is a nursing intervention and not an outcome. Choice D is incorrect as withholding pain medications may not be in the best interest of the patient's overall care and does not directly target the constipation issue.
Question 8 of 9
Nurse Beverly is giving preoperative instructions to Ian who is scheduled for an Ileostomy. Which of the following would be included?
Correct Answer: A
Rationale: The correct answer is A because an Ileostomy involves diverting the small intestine to an opening in the abdominal wall, so the urine will not be affected. The pouch collects waste from the small intestine. Nasogastric tube (B) is not typically required for an Ileostomy. Laparoscope (C) is used for visualizing the abdomen, not the bowel. Drinking liquids (D) so soon after surgery can be risky and is not recommended.
Question 9 of 9
When testing visual fields, the nurse is assessing which of the following parts of vision?
Correct Answer: A
Rationale: The correct answer is A: Peripheral vision. When testing visual fields, the nurse evaluates the ability to see objects outside the direct line of sight, which is indicative of peripheral vision. Peripheral vision helps detect objects and movement in the side vision. Distance vision (B) refers to the ability to see clearly at a distance, while near vision (C) pertains to close-up vision. Central vision (D) is essential for focusing on details and seeing straight ahead. Therefore, A is the correct choice as it specifically pertains to the assessment of visual fields.