ATI RN
Nursing Process Questions and Answers PDF 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. Waiting for the patient to complete the sentence is the most appropriate intervention as it allows the patient time to formulate their thoughts and express themselves. It shows patience and respect for the patient's communication process. B: Immediately showing objects may overwhelm the patient and not allow them to express their thoughts fully. C: Leaving the room would not address the patient's communication difficulty and could make them feel abandoned or misunderstood. D: Naming objects for the patient assumes what they are trying to say and may not accurately represent their intended message.
Question 2 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.
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
An agitated, confused client arrives in the emergency department. The client’s history includes type 1 diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
Correct Answer: C
Rationale: The correct answer is C: 10 to 15 g of a simple carbohydrate. This amount of carbohydrate is recommended for treating hypoglycemia in clients with diabetes to quickly raise blood glucose levels without causing hyperglycemia. Consuming too little carbohydrate may not effectively raise blood glucose levels, while consuming too much may lead to a rapid spike followed by a rebound hypoglycemia. Options A and B provide insufficient amounts of carbohydrate, while option D provides excessive carbohydrate, increasing the risk of hyperglycemia. Therefore, option C is the most appropriate choice for effectively treating hypoglycemia in this client.
Question 5 of 9
If a patient has elevated pulmonary vascular pressures, the nurse understands that the patient is most likely to develop which of the ff. physiological cardiac changes?
Correct Answer: D
Rationale: The correct answer is D: Right ventricular hypertrophy. Elevated pulmonary vascular pressures lead to increased resistance in the pulmonary circulation, causing the right ventricle to work harder to pump blood to the lungs. Over time, this can result in hypertrophy of the right ventricle as it adapts to the increased workload. Left atrial atrophy (A) and right atrial atrophy (C) are unlikely as the atria are not directly affected by elevated pulmonary pressures. Left ventricular hypertrophy (B) is not the correct choice as it typically occurs in response to systemic hypertension, not pulmonary hypertension.
Question 6 of 9
How many liters per minute of oxygen should be administered to the patient with emphysema?
Correct Answer: A
Rationale: The correct answer is A: 2 L/min. In emphysema, there is impaired gas exchange due to damaged lung tissue, resulting in decreased oxygen levels. Administering too high a flow rate can lead to oxygen toxicity. The standard oxygen therapy for emphysema is 1-2 L/min to maintain oxygen saturation without causing harm. Higher flow rates like 10 L/min (B) and 6 L/min (C) are excessive and can lead to oxygen toxicity. 95 L/min (D) is dangerously high and not suitable for oxygen therapy in emphysema. Therefore, A is the correct choice for safe and effective oxygen administration in emphysema.
Question 7 of 9
Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
Correct Answer: C
Rationale: Step 1: Mr. Franco's condition suggests he may need support and positioning. Step 2: Sandbags provide stability and trochanter rolls prevent hip rotation. Step 3: These help prevent pressure ulcers and maintain proper body alignment. Step 4: Hand bell and bed linen are not essential for Mr. Franco's immediate care. Step 5: Footboard and splint may not be relevant to his specific condition. Step 6: Suction machine and gloves are important but not as crucial as positioning aids for Mr. Franco. Summary: Choice C is correct as it directly addresses Mr. Franco's needs for support and positioning, while the other choices are less relevant or not as essential in this context.
Question 8 of 9
Mr. Reyes has a possible skull fracture. The nurse should:
Correct Answer: A
Rationale: The correct answer is A because signs of brain injury, such as altered level of consciousness, unequal pupil size, and clear fluid draining from the nose or ears, indicate a need for urgent medical attention. Choice B is incorrect because hemorrhaging from the oral cavity is not a common sign of a skull fracture. Choice C is incorrect as elevating the foot of the bed is not appropriate for a skull fracture but may be done for shock. Choice D is incorrect because decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.
Question 9 of 9
The spouse of a client with gastric cancer expresses concern that the couple’s children may develop this type of cancer when they’re older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
Correct Answer: A
Rationale: The correct answer is A: Type A. Individuals with blood type A have a slightly higher risk of developing gastric cancer compared to other blood types. This is due to the presence of certain antigens associated with Type A blood that may increase susceptibility to gastric cancer. In this case, the nurse mentions a 10% increased risk for individuals with Type A blood, which aligns with the known epidemiological data. Choice B: Type AB is incorrect because individuals with Type AB blood do not have a known increased risk of gastric cancer. Choice C: Type B is incorrect because individuals with Type B blood do not have a known increased risk of gastric cancer. Choice D: Type O is incorrect because individuals with Type O blood actually have a slightly lower risk of developing gastric cancer compared to individuals with Type A blood.