ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 5
The nurse would expect which of the following would be included in the plan of care/
Correct Answer: D
Rationale: Step 1: Monitoring electrolytes is essential to assess for potential imbalances due to the use of sodium bicarbonate, which can lead to hypokalemia and hypocalcemia. Step 2: Hypokalemia and hypocalcemia can result in serious complications such as cardiac arrhythmias and muscle weakness. Step 3: By monitoring electrolytes, the nurse can detect imbalances early and intervene promptly to prevent adverse effects. Summary: A: Drinking excessive water can lead to electrolyte imbalances and is not directly related to the use of sodium bicarbonate. B: Administering NaHCO3 IV is not within the nurse's scope of practice and should be done based on physician's orders. C: Continuing sodium bicarbonate for nausea may not be appropriate without monitoring electrolytes to prevent potential imbalances.
Question 2 of 5
The most likely cause of her chief complaint this morning is
Correct Answer: D
Rationale: The correct answer is D because polyuria is a common complication following hypophysectomy (removal of the pituitary gland). This procedure can disrupt the regulation of antidiuretic hormone (ADH), leading to excessive urination. Choice A is incorrect as decreased stress would not cause polyuria. Choice B is unlikely as the onset of diabetes mellitus is not a typical immediate postoperative complication. Choice C is incorrect as removal of the pituitary gland would disrupt hormone regulation, possibly leading to polyuria, rather than being an expected result.
Question 3 of 5
Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
Correct Answer: B
Rationale: The correct answer is B. Placing the patient on the right side with support to the back, pillows for body alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled is most appropriate for a patient with right-sided paralysis following a stroke. This position helps prevent contractures by maintaining proper alignment and positioning of the limbs. Placing the washcloth to curl the fingers helps prevent hand contractures. Supporting the back and keeping the hips slightly flexed also helps prevent pressure ulcers and maintains proper body alignment. Choice A is incorrect because tightly holding a rolled washcloth may cause discomfort and restrict blood flow. Choice C is incorrect because placing the patient on the back with a pillow under the knees does not address the specific needs of a patient with right-sided paralysis. Choice D is incorrect because lying on the back with trochanter rolls and a footboard does not address the specific needs of a patient with right-sided paralysis and may not prevent contractures effectively.
Question 4 of 5
Which part of the brain controls breathing?
Correct Answer: A
Rationale: The correct answer is A: Medulla. The medulla is located in the brainstem and plays a crucial role in controlling involuntary functions like breathing. It contains the respiratory center, which regulates the rate and depth of breathing. The medulla sends signals to the diaphragm and intercostal muscles to control breathing. The cerebrum (B) is responsible for higher brain functions, not breathing control. The cerebellum (C) coordinates movement and balance, not breathing. The thalamus (D) relays sensory information to the cerebral cortex, not involved in breathing regulation.
Question 5 of 5
Many neuromuscular disorders can impair respiratory function. What intervention can a home care nurse recommend to help prevent complications in patients with impaired respiratory function?
Correct Answer: C
Rationale: The correct answer is C: Elevate the head of bed. Elevating the head of the bed helps improve lung expansion and ventilation, making it easier for patients with impaired respiratory function to breathe. This position also helps prevent aspiration and reduces the risk of respiratory complications. Antibiotics (choice A) are not indicated unless specifically prescribed for an infection. Bedrest (choice B) can lead to deconditioning and worsen respiratory function. Suctioning (choice D) every 4 hours is not necessary unless there is excessive secretions present.