ATI RN
Nursing Process Exam Questions Questions
Question 1 of 5
When administering oxygen to a client, under which of the ff situations should the nurse discontinue the administration and notify the physician?
Correct Answer: C
Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.
Question 2 of 5
The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?
Correct Answer: A
Rationale: The correct answer is A because gathering and organizing needed supplies is a crucial step before performing a complex dressing change. By ensuring all necessary supplies are readily available, the nurse can streamline the process, minimize interruptions, and promote efficiency. This step also helps maintain aseptic technique and prevent the spread of infection. Deciding on goals and outcomes (B) is important but typically done as part of the care planning process, not immediately before a dressing change. Assessing the patient's readiness (C) is also important but can be done concurrently with gathering supplies. Calling for assistance (D) may be necessary in some situations, but it is not the immediate step required just before changing the dressing.
Question 3 of 5
The patient asks the nurse, “What is hypertension?” Which of the following is the best response to explain hypertension?
Correct Answer: D
Rationale: The correct answer is D because hypertension is primarily determined by peripheral vascular resistance, which refers to the resistance in the blood vessels that the heart must overcome to pump blood effectively. This is a key factor in the development of high blood pressure. Choice A is incorrect as it simplifies the concept to just the pumping action of the heart. Choice B is incorrect because hypertension is not just about having high readings on separate occasions but rather a sustained elevation in blood pressure. Choice C is incorrect as stress, activity, and emotions can influence blood pressure but are not the sole determinants of hypertension.
Question 4 of 5
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
Correct Answer: A
Rationale: The correct answer is A: Diagnosis. The nurse should proceed to the diagnosis step of the nursing process after reviewing the patient's data. In this step, the nurse will analyze the information gathered to identify the patient's health problems and needs. Given the patient's lack of voiding, abnormal kidney function, and decreased oral intake, the nurse needs to determine the underlying issues contributing to these findings. This analysis will guide the nurse in developing a plan of care to address the patient's specific health concerns. Choice B: Planning would be premature without a clear understanding of the patient's health problems, needs, and contributing factors. Choice C: Implementation would involve carrying out interventions without a thorough understanding of the patient's health issues. Choice D: Evaluation comes after the implementation of interventions to assess their effectiveness, which cannot be done without a clear diagnosis.
Question 5 of 5
Which of the ff precautions must a nurse take while caring for clients with HIV/AIDS to reduce occupational risks?
Correct Answer: A
Rationale: The correct answer is A. Transporting specimens of body fluid in leakproof containers reduces the risk of exposure to HIV/AIDS. This precaution ensures that any potentially infectious material is securely contained. Choice B is incorrect as fusion inhibitors are not prescribed for reducing occupational risks. Choice C is incorrect as it does not directly address reducing occupational risks related to HIV/AIDS. Choice D is incorrect as it is essential for a nurse to clean the client's room, but with proper precautions in place to prevent exposure to bodily fluids.