ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 9
What is a critical component of the evaluation phase in the nursing process?
Correct Answer: A
Rationale: Step 1: Evaluation phase assesses if client outcomes have been achieved. Step 2: Determines effectiveness of nursing interventions. Step 3: Validates if goals are met or adjustments are needed. Step 4: Reflects on the success of the care plan. Step 5: Choice A is correct as it directly relates to evaluating the effectiveness of nursing care. Summary: - Choice B is incorrect as revising health history is part of assessment. - Choice C is incorrect as establishing priorities is part of the planning phase. - Choice D is incorrect as formulating new nursing diagnoses is part of the diagnosis phase.
Question 2 of 9
Which nursing diagnosis is most appropriate for a client with Addison’s disease?
Correct Answer: C
Rationale: The correct answer is C, Excessive fluid volume. In Addison's disease, there is a deficiency of cortisol and aldosterone leading to sodium loss and water retention. This imbalance can result in excessive fluid volume. A) Risk for infection is not directly related to Addison's disease. B) Urinary retention is not a common symptom of Addison's disease. D) Hypothermia is not a typical manifestation of Addison's disease.
Question 3 of 9
The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?
Correct Answer: A
Rationale: The correct answer is A: Universal blood and body fluid precautions. This is recommended by the CDC to prevent the spread of HIV because the virus can be present in blood and certain body fluids. Universal precautions involve treating all blood and body fluids as potentially infectious. Incorrect choices: B: Body systems isolation - This is not specific to preventing the spread of HIV and is not recommended by the CDC. C: Laminar flow room during active infection - This is not a standard recommendation for preventing the spread of HIV. D: Needle and syringe precautions - While important in preventing needlestick injuries, it is not the primary method recommended by the CDC for preventing the spread of HIV.
Question 4 of 9
Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects would you anticipate from too rapid infusion rate?
Correct Answer: D
Rationale: Rationale: 1. Rapid infusion of hyperalimentation solutions can lead to circulatory overload due to increased fluid volume in the circulatory system. 2. Circulatory overload can result in symptoms such as hypertension, tachycardia, and edema. 3. Hypoglycemia can occur as a result of excess insulin release due to the sudden increase in glucose from the hyperalimentation solution. Summary: A. Cellular dehydration and potassium: Incorrect. Rapid infusion would lead to fluid overload, not dehydration. B. Hypoglycemia and hypovolemia: Incorrect. Hypovolemia is unlikely with rapid infusion, and hypoglycemia is a possible side effect. C. Potassium excess and CHF: Incorrect. Rapid infusion may cause circulatory overload, not CHF, and potassium excess is not a common side effect. D. Circulatory overload and hypoglycemia: Correct. These are the most likely side effects of rapid
Question 5 of 9
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
Correct Answer: C
Rationale: After a transsphenoidal adenohypophysectomy, hormone replacement therapy is needed due to the removal of the pituitary gland. This surgery is typically done to treat pituitary carcinoma, making choice C the correct answer. Pituitary carcinoma is a type of cancer that affects the pituitary gland. Choices A, B, and D are incorrect because they do not involve the pituitary gland. Esophageal carcinoma affects the esophagus, laryngeal carcinoma affects the larynx, and colorectal carcinoma affects the colon and rectum. Therefore, the correct choice, C, is the only one related to the pituitary gland and the procedure described.
Question 6 of 9
The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on potential causes of their fatigue, leading to a more in-depth exploration of the issue. Option A focuses on stress, not necessarily fatigue. Option C is too specific and may not uncover underlying causes. Option D assumes sleep duration is the only factor contributing to fatigue.
Question 7 of 9
A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct: 1. Safety: Morbidly obese patients are at higher risk of falls during transfers. 2. Assistance: Having two other personnel ensures safe transfer. 3. Weight distribution: Distributing the patient's weight among multiple helpers reduces strain. 4. Proper body mechanics: Allows for proper positioning and technique while assisting. Summary of why other choices are incorrect: B. Medication doesn't address the safety concern of transferring a morbidly obese patient. C. Reviewing activity orders is not the immediate action needed for the patient's first bathroom transfer. D. Offering a walker may not provide sufficient support for a morbidly obese patient during the transfer.
Question 8 of 9
As part of primary cancer prevention program, an oncology nurse answers questions from the public at health fair. When someone asks about the laryngeal cancer, the nurse should explain that:
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Laryngeal cancer is strongly linked to smoking and alcohol consumption. 2. Both smoking and alcohol use are modifiable risk factors, meaning they can be prevented. 3. By avoiding smoking and excessive alcohol intake, individuals can significantly reduce their risk of developing laryngeal cancer. 4. Therefore, laryngeal cancer is considered one of the most preventable types of cancer. Summary of why the other choices are incorrect: B. Inhaling polluted air can be a risk factor for laryngeal cancer, so this statement is inaccurate. C. Laryngeal cancer occurs more frequently in men than women, so this statement is incorrect. D. Squamous cell carcinoma, not adenocarcinoma, is the most common type of laryngeal cancer, making this statement incorrect.
Question 9 of 9
The nurse observes the client as he walks into the room. What information will this provide the nurse?
Correct Answer: A
Rationale: The correct answer is A because observing the client's gait while walking can provide valuable information about their physical mobility, balance, coordination, and any potential musculoskeletal issues. This assessment helps the nurse determine if the client requires any assistance, mobility aids, or further evaluation by a healthcare provider. Choices B and C are incorrect as observing gait does not directly provide information on personality or psychosocial status. Choice D is incorrect as gait observation is not specifically related to the rate of recovery from surgery. In summary, observing the client's gait is important for assessing physical mobility and identifying potential issues, making it the most relevant choice in this context.