ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 9
Three days after admission Ms. CC continued to have frequent stools. Her oral intake of both fluids and solids are poor. Her physician ordered parenteral hyperalimentation. Hyperalimentation solutions are:
Correct Answer: D
Rationale: The correct answer is D: Hyperosmolar solutions used primarily to reverse negative nitrogen balance. Rationale: 1. Hyperalimentation solutions are designed to provide essential nutrients intravenously. 2. Hyperosmolar solutions have a higher osmolarity compared to body fluids, providing concentrated nutrition. 3. Negative nitrogen balance occurs when the body breaks down more protein than it synthesizes, requiring additional protein intake. 4. Hyperosmolar solutions can provide adequate protein and nutrients to reverse negative nitrogen balance. Summary: A: Hypotonic solutions do not increase osmotic pressure, but rather decrease it. B: Hypertonic solutions are not primarily used for hydration in this context. C: Alkalizing solutions are not the primary purpose of hyperalimentation and do not directly address cellular sweating.
Question 2 of 9
An adult has a central line in his right subclavian vein. The nurse is to change the tubing. Which of the following should be done?
Correct Answer: C
Rationale: The correct answer is C: Close the roller clamp on the new tubing after priming it. This step ensures that the tubing is primed with the solution and ready for use while preventing air from entering the central line. Option A is incorrect because using the present solution may introduce contamination. Option B is incorrect as connecting tubing before running fluid can introduce air into the line. Option D is incorrect as positioning the client on the right side does not prevent air embolism during tubing change.
Question 3 of 9
The nurse teaches a client with newly diagnosed hypothyroidism about the need for thyroid hormone replacement therapy to restore normal thyroid function. Which thyroid preparation is the agent of choice for thyroid hormone replacement therapy?
Correct Answer: D
Rationale: Step 1: Levothyroxine (Synthroid) is the synthetic form of the thyroid hormone T4, the main hormone produced by the thyroid gland. Step 2: Levothyroxine is the preferred agent for thyroid hormone replacement therapy in hypothyroidism due to its stable and consistent potency. Step 3: Levothyroxine is well-absorbed by the body and has a long half-life, allowing for once-daily dosing. Step 4: Other choices are incorrect because Methimazole is used to treat hyperthyroidism, Livothyronine is a form of T3 hormone not commonly used for replacement therapy, and Thyroid USP dessicated is derived from animal thyroid glands and has inconsistent hormone content. Summary: Levothyroxine (Synthroid) is the preferred choice for thyroid hormone replacement therapy due to its synthetic nature, stable potency, good absorption, and long half-life. Other options are not
Question 4 of 9
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to gather relevant information and focus the interview on the patient's needs. This step helps establish rapport and ensures the patient is actively involved in the conversation. Incorrect Choices: A: Beginning with introductions is important, but after setting the agenda, it is more crucial to address the patient's concerns. C: Explaining that the interview will be over in a few minutes is not appropriate as it may rush the patient and hinder open communication. D: Telling the patient about administering medications in 1 hour is not relevant at this stage and does not address the patient's immediate needs.
Question 5 of 9
Which of the ff finding would confirm that a female client has mastitis? Choose all that apply
Correct Answer: C
Rationale: The correct answer is C because mastitis typically presents with swollen, firm, and hard breasts due to inflammation and infection of the breast tissue. This occurs as a result of milk stasis and bacterial infection. Option A is incorrect because a crack in the nipple or areola can be indicative of nipple trauma or infection, not necessarily mastitis. Option B is incorrect because multiple lumps within the breast tissue may suggest fibrocystic changes or breast cancer, but not specifically mastitis. Option D is incorrect because enlargement of the axillary lymph nodes is more commonly seen in breast cancer, not mastitis.
Question 6 of 9
What is the purpose of pursed lip breathing?
Correct Answer: A
Rationale: The correct answer is A because pursed lip breathing helps to slow down and control the exhalation process, allowing the individual to exhale a smaller volume of air with more force. This helps to prevent air trapping in the lungs, improve oxygen exchange, and reduce shortness of breath. B: Incorrect - Pursed lip breathing does not increase expiration but rather controls it. C: Incorrect - While pursed lip breathing can promote deep breathing and better oxygen exchange, its primary purpose is to regulate exhalation volume. D: Incorrect - Pursed lip breathing does not specifically target the upper thorax but rather facilitates a more efficient breathing pattern by reducing air trapping in the lungs.
Question 7 of 9
An oncology nurse educator is speaking to a women’s group about breast cancer. Questions and comments from the audience reveal a misunderstanding of some aspects of the disease. Various members of the audience have made all of the following statements. Which one is accurate?
Correct Answer: D
Rationale: The correct answer is D: Men can develop breast cancer. This is accurate because although breast cancer is more common in women, men can also develop the disease due to the presence of breast tissue in their bodies. This is a crucial point to emphasize to raise awareness about breast cancer among men. Incorrect choices: A: Mammography is not the most reliable method for detecting breast cancer, as it may not detect all types of breast cancer. B: Breast cancer is not the leading killer of women of childbearing age, as there are other leading causes of death in this age group. C: Breast cancer does not always require a mastectomy; treatment options vary depending on the individual case. Summary: Choice D is correct as it highlights the important fact that men can also develop breast cancer, which is often overlooked. Choices A, B, and C are incorrect due to inaccuracies or oversimplifications of the facts related to breast cancer detection, statistics, and treatment.
Question 8 of 9
Which of the following is information the nurse would be correct in giving the patient about smoking and its effect on BP?
Correct Answer: A
Rationale: The correct answer is A: It is associated with stages 1 and 2 hypertension. Smoking is a major risk factor for developing hypertension, especially stages 1 and 2. Nicotine in cigarettes can lead to vasoconstriction, increased heart rate, and overall elevated blood pressure. This information is crucial for patients to understand the direct impact of smoking on their blood pressure levels. Choice B is incorrect because smoking does indeed affect BP regulation by causing vasoconstriction and elevated heart rate. Choice C is incorrect as smoking actually causes vasoconstriction rather than vasodilation. Choice D is incorrect because smoking does lead to sustained elevation of blood pressure, especially in the long term.
Question 9 of 9
The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?
Correct Answer: A
Rationale: The correct answer is A: Measure the client’s oral temperature. This is the best follow-up because it directly assesses the client's body temperature, providing objective data to confirm the presence of fever. It is essential to gather accurate information to guide appropriate interventions. Asking a colleague for assistance (B) may not address the immediate need for temperature assessment. Giving the client a clean gown and warm blankets (C) may provide comfort but does not address the need for temperature measurement. Obtaining an order for blood cultures (D) is not the initial priority when the client is showing signs of fever; temperature measurement is the first step in assessing the client's condition.