ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 9
What is the rationale for giving Mr. Franco frequent mouth care?
Correct Answer: B
Rationale: The correct answer is B because providing frequent mouth care to Mr. Franco is important to remove dried blood when the tongue is bitten during a seizure. This is crucial for preventing infection and promoting oral hygiene. Choices A, C, and D are incorrect because the primary reason for mouth care in this case is to address the physical consequences of a seizure, such as tongue biting and potential injury, rather than thirst, tactile stimulation, or prevention of oral mucosal issues related to mouth breathing in a comatose patient.
Question 2 of 9
A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
Correct Answer: A
Rationale: The correct answer is A: Reassess the patient and situation. The nurse should reassess to determine the cause of the pressure ulcer, evaluate the effectiveness of the current turning schedule, and identify any contributing factors. This allows for a more targeted intervention plan. B: Incorrect. Simply increasing the frequency of turning may not address the underlying issue causing the pressure ulcer. C: Incorrect. Delegating turning to nursing assistive personnel without reassessment may not address the root cause of the pressure ulcer. D: Incorrect. Applying medication without reassessment may not address the underlying cause of the pressure ulcer and could potentially worsen the condition.
Question 3 of 9
Toni’s disease process involves a sacral plexus. Assessment should include:
Correct Answer: D
Rationale: The correct answer is D because a disease process involving the sacral plexus can impact bladder function (choice A), sexual activity (choice B), and bowel management (choice C). The sacral plexus is responsible for innervating pelvic organs and lower limb muscles, so dysfunction in this area can lead to issues in these functions. Bladder problems can manifest as urinary retention or incontinence, sexual activity may be affected due to changes in sensation or muscle control, and bowel management can be disrupted leading to constipation or incontinence. Therefore, assessing all these areas is crucial to understand the full impact of the disease process on the individual's quality of life.
Question 4 of 9
After the surgical incision has been clised and the anesthesia has wear-off, the patient is extubated and transferred to the postanesthesia care unit (PACU). Who is responsible for transferring the patient?
Correct Answer: D
Rationale: The correct answer is D: anesthesiologist. The anesthesiologist is responsible for transferring the patient to the PACU as they are in charge of the patient's anesthesia management throughout the surgery. They are trained to assess the patient's condition post-surgery, manage any immediate postoperative complications, and ensure a smooth transition to the PACU staff for continued care. The circulating nurse (A) is responsible for managing the operating room environment, the scrub nurse (B) assists the surgeon during the surgery by passing instruments, and the surgeon (C) performs the surgical procedure but does not typically transfer the patient to the PACU.
Question 5 of 9
A college student goes to the college clinic and asks the best way to avoid contracting an STD. The nurse provides the clinic’s standard STD teaching. Which statement by the student indicates the need for additional instruction?
Correct Answer: D
Rationale: The correct answer is D. This statement indicates a need for additional instruction because questioning a partner about past sexual encounters may not be a reliable method to avoid STDs. Here's the rationale: 1. A: Correct - Acknowledges the reality that engaging in sexual activity carries risks, even with precautions. 2. B: Correct - Emphasizes that abstinence is the most effective way to prevent STD transmission. 3. C: Correct - Using a condom with spermicide can reduce the risk of STD transmission, although it's not foolproof. 4. D: Incorrect - Relying solely on partner questioning is not a comprehensive or foolproof method to prevent STDs. It overlooks the potential for misinformation or lack of disclosure from the partner.
Question 6 of 9
Which of the following nursing activities is an example of evaluation?
Correct Answer: A
Rationale: The correct answer is A because checking a client's blood pressure after administering medication assesses the effectiveness of the intervention. Evaluation involves determining if the desired outcomes were achieved. Administering oxygen therapy (B) is an implementation task. Developing a plan of care (C) is part of the assessment and planning phase. Teaching about dietary options (D) is part of the implementation phase. In conclusion, only option A involves assessing the outcome of an intervention, making it the correct choice for evaluation.
Question 7 of 9
While receiving radiation therapy for the treatment of breast cancer, a client complains of dysphagia and skin texture changes, at the radiation site. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications, and promote healing?
Correct Answer: B
Rationale: The correct answer is B: Eat a diet high in protein and calories to optimize tissue repair. Rationale: 1. Protein is essential for tissue repair and healing, which can help counteract the effects of radiation therapy on the skin and swallowing function. 2. Calories are necessary for energy to support the body's healing processes during radiation therapy. 3. A diet high in protein and calories can help maintain overall nutritional status and promote recovery. Incorrect Choices: A: Washing the radiation site vigorously can further irritate the skin, leading to more complications. C: Cool compresses may not be suitable for radiation-induced skin reactions and may not address the underlying issue of dysphagia. D: Drinking warm fluids may not directly address the need for optimal tissue repair and healing.
Question 8 of 9
Which of the ff statements justifies the administration of the prescribed anticonvulsant phenytoin to a client before the intracranial surgery?
Correct Answer: A
Rationale: Step 1: Phenytoin is an anticonvulsant used to prevent seizures. Step 2: Anticonvulsants are often given before surgery to reduce the risk of seizures during and after the procedure. Step 3: In the context of intracranial surgery, controlling seizures is crucial to prevent complications like increased intracranial pressure. Step 4: Therefore, administering phenytoin before surgery helps in reducing the risk of seizures before and after the procedure. Summary: - Option B (avoid intraoperative complications) is too broad and doesn't directly relate to the use of phenytoin. - Option C (reduce cerebral edema) is not the primary indication for phenytoin in this scenario. - Option D (prevent postoperative vomiting) is not a common reason for administering phenytoin before intracranial surgery.
Question 9 of 9
A patient has chronic respiratory acidosis related to long-standing lung disease. Which of the following problems is the cause?
Correct Answer: C
Rationale: The correct answer is C: Hypoventilation. In chronic respiratory acidosis, the lungs cannot effectively eliminate carbon dioxide, leading to an accumulation of CO2 in the blood, causing acidosis. Hypoventilation results in decreased removal of CO2, exacerbating the acidosis. A: Hyperventilation would lead to respiratory alkalosis, not acidosis. B: Loss of acid by kidneys would result in metabolic alkalosis, not respiratory acidosis. D: Loss of base by kidneys would lead to metabolic acidosis, not respiratory acidosis. In summary, the main issue in chronic respiratory acidosis is inadequate elimination of CO2 due to hypoventilation, leading to acidosis.