ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 9
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
Correct Answer: A
Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully. Choice B may overwhelm the patient, Choice C disrupts the communication process, and Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.
Question 2 of 9
A man with a history of diabetes and chronic lung disease is admitted to the hospital with prostate cancer. He has all the following symptoms. Which should the nurse address first?
Correct Answer: C
Rationale: The correct answer is C: Respiratory rate 36/min. In this case, the nurse should address the respiratory rate first due to the patient's chronic lung disease, indicating potential respiratory distress. High respiratory rate may signify hypoxia, infection, or worsening lung function, posing immediate life-threatening risks. Addressing this symptom promptly is crucial to prevent respiratory failure. Fever (A) and difficulty urinating (B) are important but not as urgent as addressing potential respiratory distress. Painful legs and feet (D) may indicate peripheral neuropathy related to diabetes, which is important but not as critical as addressing the respiratory issue.
Question 3 of 9
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, “I have been so constipated lately.” How should the nurse respond?
Correct Answer: C
Rationale: The correct answer is C. The nurse should respond by asking, “Do you take anything to help your constipation?” This response shows active listening and gathers more information about the woman’s current management of constipation. It allows the nurse to assess the woman's current treatment regimen and potential underlying causes. Choice A is incorrect as it diverts the conversation to chest problems, which is unrelated to the woman's primary concern of constipation. Choice B is incorrect as it suggests a potentially harmful solution without assessing the woman's current treatment or determining the cause of her constipation. Choice D is incorrect as it generalizes bowel problems with aging without addressing the woman's specific issue or management.
Question 4 of 9
A brain abscess is a collection of pus within the substance of the brain and is caused by:
Correct Answer: D
Rationale: The correct answer is D because a brain abscess can be caused by direct invasion of the brain, spread of infection by other organs, and spread of infection from nearby sites. Direct invasion occurs when bacteria enter the brain tissue directly, such as through trauma or surgery. Infections from other organs, like the lungs or heart, can spread through the bloodstream to the brain. Infections from nearby sites, such as the ears or sinuses, can also spread to the brain. Therefore, all of these mechanisms can lead to the formation of a brain abscess. Choices A, B, and C individually do not cover all the possible causes of a brain abscess, making D the correct choice.
Question 5 of 9
Mr. Reyes has a possible skull fracture. The nurse should:
Correct Answer: A
Rationale: The correct answer is A because observing for signs of brain injury is crucial in assessing a possible skull fracture. Signs may include altered mental status, headache, nausea, vomiting, and unequal pupil size. Choice B is incorrect as hemorrhaging from the oral cavity may not always be present in skull fractures. Choice C is incorrect as elevating the foot of the bed is not recommended for a possible skull fracture. Choice D is incorrect as decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.
Question 6 of 9
A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Anxiety related to barium enema. This is the correct choice because nursing diagnoses should focus on the patient's actual or potential health problems, not just medical conditions. Anxiety is a common response to medical procedures like a barium enema. It is essential for the nurse to address the patient's emotional and psychological needs. Summary: B: Impaired gas exchange related to asthma is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on the patient's response to the medical condition. C: Impaired physical mobility related to incisional pain is a potential nursing diagnosis, but the focus should be on the patient's response to the pain, not just the pain itself. D: Nausea related to adverse effect of cancer medication is also a medical diagnosis. Nursing diagnoses should address the patient's response to the medication side effects, not just the side effects themselves.
Question 7 of 9
A factory worker suffered a chemical burn to the eye and arrives at the Emergency department. What is the first action of the nurse?
Correct Answer: D
Rationale: The correct answer is D: flush the eye continuously with sterile solution. This is the first action because it helps to remove the chemical from the eye, preventing further damage. Flushing with sterile solution dilutes and washes away the chemical, reducing the risk of ongoing injury. Applying a cold compress (A) may help with pain but does not address the chemical exposure. Applying a bandage (B) can trap the chemical and worsen the injury. Performing an assessment (C) should come after immediate treatment to ensure proper care but should not delay flushing the eye.
Question 8 of 9
What are the signs of organ rejection a nurse should closely monitor for when caring for a client after heart transplantation? Choose all that apply
Correct Answer: B
Rationale: The correct answer is B: Dyspnea. Dyspnea is a common sign of organ rejection after heart transplantation, indicating possible heart failure. Low white blood cell count (A) is not typically a direct sign of organ rejection. ECG changes (C) may occur but are not specific to organ rejection. Fever (D) is a non-specific symptom and can be caused by various factors. Dyspnea is a key indicator that the transplanted heart is not functioning properly and should be closely monitored.
Question 9 of 9
A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?
Correct Answer: C
Rationale: Correct Answer: C - Tracheostomy set Rationale: 1. Immediate airway management: After thyroidectomy, there is a risk of airway compromise due to swelling or bleeding. Tracheostomy set ensures immediate access to secure the airway. 2. Emergency intervention: In case of respiratory distress or airway obstruction post-surgery, a tracheostomy set allows for prompt and effective intervention. 3. Patient safety and priority: Ensuring airway patency is crucial for the client's survival and takes precedence over other equipment. Summary of other choices: A: Indwelling urinary catheter kit - Not directly related to post-thyroidectomy care. B: Cardiac monitor - Important but secondary to airway management in this situation. D: Humidifier - Not essential for immediate post-thyroidectomy care.