ATI RN
Nursing Process Exam Questions Questions
Question 1 of 5
What is the role of a nurse during scratch test to detect allergies?
Correct Answer: A
Rationale: The correct answer is A: Applying the liquid test antigen. During a scratch test to detect allergies, the nurse's role is to apply the liquid test antigen onto the skin to observe the body's reaction. This antigen contains potential allergens that may trigger a response in allergic individuals. By applying this antigen, the nurse can assess if the patient develops a raised wheal or redness at the site, indicating an allergic reaction. This step is crucial in identifying specific allergens causing the patient's symptoms. Choices B, C, and D are incorrect as determining the type of allergy, measuring the length and width of the reaction, and documenting the findings are all important steps but do not directly relate to the initial action of applying the test antigen during a scratch test.
Question 2 of 5
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse’s analysis are:
Correct Answer: C
Rationale: The correct answer is C: Drop in blood pressure and rise in heart rate. After a splenectomy, the client is at risk for orthostatic hypotension due to decreased blood volume. A drop in blood pressure and a compensatory rise in heart rate are common orthostatic changes. This occurs because the body tries to maintain perfusion to vital organs. A rise in blood pressure and heart rate (Choice A) would not align with orthostatic changes. A rise in blood pressure and drop in heart rate (Choice B) is contradictory to the body's compensatory response to maintain perfusion. Therefore, the most supportive vital sign values for abnormal orthostatic changes in this client would be a drop in blood pressure and a rise in heart rate.
Question 3 of 5
The nurse practitioner assesses a client in the physician’s office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
Correct Answer: B
Rationale: The correct answer is B because the assessment findings of pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers are classic manifestations of systemic lupus erythematosus (SLE). Pericarditis can present as chest pain aggravated by deep breathing or lying flat, photosensitivity refers to skin rashes triggered by sunlight exposure, polyarthralgia involves joint pain in multiple joints, and painful mucous membrane ulcers are common in the mouth or nose. These findings align with the diagnostic criteria for SLE. Choices A, C, and D are incorrect because they do not align with the typical presentation of SLE. Choice A includes facial erythema which is a common symptom, but the presence of profuse proteinuria, pleuritis, fever, and weight loss are not specific to SLE. Choices C and D include symptoms like weight gain, hypothermia, and edema which are not characteristic of SLE. In summary
Question 4 of 5
The nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client’s blood and body fluids, the nurse uses standard precautions, which include:
Correct Answer: A
Rationale: The correct answer is A. Standard precautions include wearing gloves when there is a potential for contact with blood or body fluids. Emptying a bedpan involves contact with bodily fluids, thus gloves are necessary to prevent exposure to pathogens. Choice B is incorrect because wearing a gown and protective eyewear is not necessary for obtaining a urine specimen via catheterization unless there is a risk of splashing or spraying of fluids. Choice C is incorrect as needles should always be disposed of in a proper sharps container with the cap secured to prevent accidental needlestick injuries. Choice D is incorrect because applying eyedrops does not involve contact with blood or body fluids, so wearing gloves is not necessary according to standard precautions.
Question 5 of 5
The normal range of hemoglobin in the blood of an adult:
Correct Answer: C
Rationale: The normal range of hemoglobin in adult blood is typically between 12-18 g/dL. This range is the most common and widely accepted range based on clinical guidelines and research studies. Hemoglobin levels outside this range may indicate anemia or other health conditions. Choice A (7-11 mg) is too low for normal hemoglobin levels in adults and indicates severe anemia. Choice B (14-20 mg) is slightly higher and could be normal for some individuals, but generally, 12-18 g/dL is the standard range. Choice D (20-26 mg) is too high and may indicate dehydration or other medical conditions.