ATI RN
Nursing Process Questions Questions
Question 1 of 5
The patient is dangling at the bedside and states, “Oh, my stomach is tearing open.” Which of the following actions should the nurse immediately take when dehiscence occurs?
Correct Answer: B
Rationale: The correct answer is B: Have patient lie down. When a patient experiences dehiscence (surgical wound separation), lying down helps reduce tension on the wound, minimizing the risk of further tearing. This position also allows the nurse to assess the wound properly. Choice A is incorrect because sitting upright can increase intra-abdominal pressure, worsening the dehiscence. Choice C is incorrect as slowing IV fluids is not a priority in managing dehiscence. Choice D is incorrect because obtaining a sterile suture set should only be done by a healthcare provider and is not the immediate action needed for dehiscence.
Question 2 of 5
Which points should a nurse includes in the discharge teaching plan for a client after cardiac surgery?
Correct Answer: B
Rationale: The correct answer is B because it addresses the importance of notifying the physician about a painless lump at the top of the chest incision, which could indicate a serious complication like a seroma or hematoma. This is crucial for early detection and intervention. A is incorrect because showers are generally allowed after cardiac surgery as long as the incisions are kept clean and dry. C is incorrect because support hose or elastic stockings are typically recommended to be worn during the day and removed at night to prevent swelling and promote circulation. D is incorrect because resuming sexual relations after cardiac surgery should be based on individual recovery and should be discussed with the healthcare provider, rather than a standard timeframe.
Question 3 of 5
Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?
Correct Answer: B
Rationale: The correct answer is B because monitoring for swelling and heaviness of legs is essential in preventing falls, which can be caused by conditions like edema or circulatory issues. Swollen or heavy legs can affect mobility and balance, increasing the risk of falls. This intervention helps identify potential issues early and implement preventive measures. Choice A is incorrect as monitoring for chest pain and LDL levels pertains more to cardiovascular health than fall prevention. Choice C is incorrect because monitoring postural changes in BP is important for managing hypertension, not necessarily for preventing falls. Choice D is incorrect as monitoring temperature for mild fever is more related to identifying infections rather than preventing falls.
Question 4 of 5
A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse during the morning assessment. Early in the afternoon, the patient’s daughter runs out of the room and says, “My mother can’t talk. Somebody help!” Which response by the nurse is best?
Correct Answer: B
Rationale: The correct answer is B. The nurse should do a quick assessment to confirm the change in the patient's status, then notify the RN or physician. This is the best response because the nurse needs to immediately assess the patient's condition to ensure prompt intervention if needed. By confirming the change in the patient's status, the nurse can provide the necessary information to the healthcare team for appropriate evaluation and management. The other choices are incorrect because: A does not address the urgency of the situation, C involves unnecessary delay by waiting for the speech therapist, and D is not appropriate as the nurse should be the one assessing and notifying the healthcare team.
Question 5 of 5
An adult is being taught about a healthy diet. How can the food pyramid help guide the client on his diet?
Correct Answer: C
Rationale: The correct answer is C because the food pyramid suggests daily food choices based on the different food groups. It provides a visual guide on the proportions of each food group to consume for a balanced diet. It does not specify the exact number of servings (A), calculate calories (B), or divide food into four basic groups (D). The food pyramid is a tool to help individuals make healthier food choices by emphasizing variety and moderation.