ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 9
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Lymphangitis is an inflammation of lymphatic vessels. 2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection. 3. Nurse should notify the physician for further evaluation and treatment. 4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification. 5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification. 6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.
Question 2 of 9
A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo- oopherectomy with tumor secretion, omentectomy, appendectomy, and lymphadenopathy. During the second postoperative day, which of the following assessment findings would raise concern in the nurse?
Correct Answer: D
Rationale: The correct answer is D: Shallow breathing and increasing lethargy. This finding could indicate a potential respiratory complication such as atelectasis or pneumonia, which are common postoperative complications. Shallow breathing can lead to inadequate oxygenation and ventilation, causing lethargy due to decreased oxygen delivery to tissues. It is crucial to assess and address respiratory issues promptly to prevent further complications. A: Abdominal pain is expected postoperatively and can be managed with pain medications. B: Serous drainage from the incision is a normal finding after surgery and indicates the wound is healing properly. C: Hypoactive bowel sounds are common after surgery due to decreased peristalsis and can be managed with interventions such as early ambulation and medications.
Question 3 of 9
During the initial assessment, he is placed in a modified Trendelenburg position. What desired effect should the position have on the client?
Correct Answer: A
Rationale: The modified Trendelenburg position involves placing the client with their legs elevated higher than their head. This position promotes venous return to the heart, increasing preload and cardiac output, thereby leading to an increase in blood pressure. Elevating the legs helps to reduce peripheral edema and improve circulation. Therefore, the correct answer is A. Choice B is incorrect because the Trendelenburg position does not directly affect the respiratory rate. Choice C is incorrect as the position is not intended to increase heart rate but rather improve venous return. Choice D is also incorrect as the primary goal of the Trendelenburg position is not to decrease blood loss, although it may help in some cases by improving circulation.
Question 4 of 9
Which of the ff. interventions can help minimize complications related to Hypercalcemia?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Hypercalcemia can lead to dehydration due to increased urine output. 2. Encouraging 3 to 4 L of fluid daily helps prevent dehydration and promote renal excretion of excess calcium. 3. Adequate hydration reduces the risk of kidney stones and other complications associated with hypercalcemia. Summary of why other choices are incorrect: - Choice B (bed rest) does not directly address hypercalcemia complications. - Choice C (cough and deep breathe) is unrelated to managing hypercalcemia. - Choice D (apply heat to painful areas) does not address the underlying cause of hypercalcemia or its complications.
Question 5 of 9
A client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?
Correct Answer: D
Rationale: The correct answer is D: Sigmoidoscopy. This procedure allows direct visualization of the lower colon and rectum, enabling the detection of colorectal cancer. Stool hematest (A) detects blood in the stool but does not confirm cancer. Abdominal CT (B) can show abnormalities but is not specific for colorectal cancer. CEA scan (C) measures a tumor marker but is not definitive for diagnosis. Sigmoidoscopy (D) is the gold standard for diagnosing colorectal cancer as it allows for direct visualization and tissue biopsy.
Question 6 of 9
When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?
Correct Answer: C
Rationale: The correct answer is C: Weak, slow pulse. Circulatory overload typically presents with signs of fluid volume excess, such as moist gurgling respirations, distended neck veins, dyspnea, and coughing. A weak, slow pulse is not a characteristic sign of circulatory overload, as the heart rate may actually be elevated due to the increased fluid volume. Therefore, a weak, slow pulse would not be likely to occur in this scenario.
Question 7 of 9
A client has possible malignancy of the colon, and surgery is scheduled. The rationale for administering Neomycin preoperatively is to:
Correct Answer: C
Rationale: The correct answer is C because Neomycin is given preoperatively to decrease and retard the growth of normal bacteria in the intestines. This helps reduce the risk of infection during surgery by minimizing the number of bacteria present in the colon. Options A, B, and D are incorrect because Neomycin is not given to prevent infection postoperatively, eliminate the need for preoperative enemas, or treat cancer of the colon. The main purpose of administering Neomycin in this scenario is to create a sterile surgical field by reducing the normal flora in the intestines.
Question 8 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 9 of 9
According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
Correct Answer: D
Rationale: The correct answer is D: Risk for body image disturbance. In the context of Maslow's hierarchy of needs, physiological needs take precedence over psychological needs. For a client in the intensive care unit with congestive heart failure, ensuring physiological needs like airway clearance, urinary elimination, and coping are addressed first is crucial for survival. Body image disturbance is a higher-level psychological need and can be addressed once basic physiological needs are met. Therefore, addressing the risk for body image disturbance would have the lowest priority compared to the other options provided.