ATI RN
Fundamentals of Nursing Nursing Process Questions Questions
Question 1 of 9
The physician prescribes didanosone (ddl [Videx]), 200mg PO every 12 hours, for a client with acquired immunodeficiency syndrome (AIDS) who is intolerant to zidovudine (azidothymidine ,AZT [Retrovir]). Which condition in the client’s history warrants cautious of this drug?
Correct Answer: A
Rationale: The correct answer is A: Peripheral neuropathy. Didanosine (ddl) can cause peripheral neuropathy as a side effect, which can exacerbate existing neuropathy. The client's history of peripheral neuropathy warrants caution with this drug to prevent further nerve damage. Incorrect choices: B: Hypertension - Didanosine is not contraindicated in hypertension. C: Diabetes mellitus - While monitoring blood sugar levels is important, didanosine does not directly affect diabetes. D: Asthma - Didanosine does not have a significant impact on asthma. In summary, the client's pre-existing peripheral neuropathy makes it important to exercise caution with didanosine to avoid worsening this condition.
Question 2 of 9
Rodolfo, an 85 year old, is admitted for comtinuous cramping pain as the result of intermittent claudication. When conducting an initial physical assessment, the nurse is unable to palpate the pedal pulses. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action. Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.
Question 3 of 9
Other signs of hypovolemia includes all of the following except:
Correct Answer: C
Rationale: The correct answer is C because decreased pulse rate and widened pulse pressure are not signs of hypovolemia. In hypovolemia, the body tries to compensate by increasing the heart rate and narrowing the pulse pressure to maintain adequate blood flow. A is incorrect as dry mucous membranes and soft eyeballs are signs of dehydration. B is incorrect as increased hematocrit and hemoglobin are indicators of hemoconcentration in hypovolemia. D is incorrect as increased lethargy and confusion can be seen in severe hypovolemia due to poor perfusion of vital organs.
Question 4 of 9
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do these signs suggest?
Correct Answer: A
Rationale: The presence of redness, swelling, and induration at the wound site are indicative of infection. Redness and swelling suggest inflammation, while induration indicates tissue hardening and can be a sign of infection spreading. Infection can delay healing and lead to complications if not treated promptly. Evisceration refers to wound opening with protrusion of internal organs, not indicated by the symptoms. Dehiscence is the partial or complete separation of wound layers, not represented by the symptoms. Hemorrhage involves excessive bleeding, which is not described in the scenario. Therefore, choice A is correct as it aligns with the signs observed and is the most appropriate response for the situation.
Question 5 of 9
In giving health instructions, the nurse should infrom the client about the risk fsctors associated with coronary artery disease. Which of the following controllable risk factors is closely linked to the development of MI?
Correct Answer: B
Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease. Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI). Step 3: Age is a risk factor for CAD but not directly linked to MI development. Step 4: Medication usage may impact risk factors but is not a direct cause of MI. Step 5: Gender can influence risk but is not the primary factor in MI development.
Question 6 of 9
The following statements are on a patient’s nursing care plan. Which statement will the nurse use as an outcome for a goal of care? The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the
Correct Answer: A
Rationale: The correct answer is A because it is specific, measurable, achievable, relevant, and time-bound (SMART) - the patient verbalizing a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. This outcome is immediate, concrete, and directly related to the goal of managing pain. Choice B is incorrect as it lacks specificity and a clear timeframe for evaluation. Choice C is incorrect because the outcome is vague and does not specify when the patient needs to understand the dietary changes. Choice D is incorrect because the timeframe is provided but the outcome is not specific enough and does not directly relate to the goal of pain management.
Question 7 of 9
A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
Correct Answer: D
Rationale: The correct answer is D: Leucovorin. Leucovorin is given during methotrexate therapy to protect normal cells by acting as a rescue agent that helps to reduce the toxic effects of methotrexate. It works by enhancing the efficacy of methotrexate in cancer cells while reducing its toxicity in normal cells. Probenecid (A) is not used to protect normal cells during methotrexate therapy. Cytarabine (B) and Thioguanine (C) are other chemotherapeutic agents and are not typically given to protect normal cells during methotrexate therapy.
Question 8 of 9
The nurse will monitor J.E. for the following signs and symptoms:
Correct Answer: A
Rationale: The correct answer is A. 1. Change in level of consciousness is crucial in assessing neurological status. 2. Tachypnea indicates possible respiratory distress or oxygenation issues. 3. Tachycardia may suggest a cardiovascular problem or inadequate perfusion. 4. Petechiae can be a sign of bleeding disorders or sepsis. Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more indicative of a cardiac event rather than monitoring for J.E.'s signs and symptoms. Option C is incorrect because loss of consciousness, bradycardia, and leg pain do not align with the signs and symptoms to monitor for J.E. Option D is incorrect because bradycardia, chest pain, and oliguria are not as comprehensive as the signs and symptoms listed in option A for monitoring J.E.
Question 9 of 9
Which method of data collection will the nurse use to establish a patient’s database?
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather objective data directly from the patient's body, such as vital signs, appearance, and physical findings. It is essential for establishing a patient's baseline health status and identifying any abnormalities or changes. Reviewing literature (A) is important but not a method of data collection. Checking orders (B) is part of the assessment process but does not involve direct data collection. Ordering medications (D) is a clinical intervention and not a data collection method.