ATI RN
Nursing Process Exam Questions Questions
Question 1 of 9
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 9
A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?
Correct Answer: D
Rationale: The correct answer is D because a respiratory rate of 8 breaths/min indicates respiratory depression, a serious adverse effect of morphine. Morphine is a central nervous system depressant that can suppress the respiratory drive, leading to hypoventilation and potentially respiratory failure. This is a life-threatening complication that requires immediate intervention. A: Voiding of 350mL of concentrated urine is not typically associated with morphine use. B: An irregular heart rate of 82 beats/min is within a normal range and not a common adverse effect of morphine. C: Pupils constricted and equal is a common side effect of morphine due to its action on the central nervous system, not necessarily indicating an adverse effect.
Question 3 of 9
What orders would likely be included fro a client diagnosed with multiple myeloma?
Correct Answer: C
Rationale: The correct answer is C, Corticosteroid therapy. In multiple myeloma, corticosteroids are commonly used to help reduce inflammation, suppress the immune system, and slow the growth of cancer cells. This treatment can help manage symptoms and improve quality of life for the client. A: Bed rest is not typically prescribed for multiple myeloma unless there are specific complications requiring immobilization. B: Fluid restriction is not a common treatment for multiple myeloma unless there is a specific need to manage fluid balance. D: Calcium replacement therapy may be necessary in some cases of multiple myeloma due to bone involvement, but it is not a primary treatment option compared to corticosteroid therapy in managing the disease.
Question 4 of 9
In the presence of coma or unconsciousness, the major therapeutic measure includes:
Correct Answer: A
Rationale: The correct answer is A: Maintenance of a clear airway. In cases of coma or unconsciousness, ensuring a clear airway is crucial to prevent respiratory complications and maintain oxygenation. This involves positioning the patient correctly, suctioning if necessary, and monitoring breathing. Choice B, good nursing care, is too broad and does not address the immediate priority of airway management. Choice C, retention of a catheter, is irrelevant to managing a coma or unconsciousness. Therefore, the correct therapeutic measure in this scenario is to focus on maintaining a clear airway to support respiratory function.
Question 5 of 9
In order to educate clients, the nurse should understand that the most common site of cancer for a female is the:
Correct Answer: C
Rationale: The correct answer is C: Uterine body. The rationale is that the most common site of cancer for females is uterine body, specifically endometrial cancer. This is due to the high prevalence of hormonal imbalances and estrogen exposure, which are risk factors for this type of cancer. The other choices, A: Uterine cervix, B: Vagina, and D: Fallopian tube, are less common sites of cancer in females compared to the uterine body. Understanding the prevalence and risk factors associated with each site of cancer is crucial for nurses to educate clients effectively.
Question 6 of 9
When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?
Correct Answer: B
Rationale: The correct answer is B: Focused. When a nurse inspects a postoperative incision site for infection, they are conducting a focused assessment. This type of assessment is specific to a particular issue or body system, in this case, the incision site. By focusing solely on the incision site, the nurse can thoroughly evaluate for signs of infection, such as redness, swelling, warmth, or discharge. A: Complete assessments involve a comprehensive evaluation of all body systems and are not necessary for this specific situation. C: General assessments are broad and not targeted towards a specific issue like infection at an incision site. D: Time-lapse assessments involve comparing current findings to previous assessments over a period of time, which is not relevant to immediately identifying signs of infection. In summary, the correct answer is focused because it allows for a detailed evaluation of the incision site specifically for signs of infection, unlike the other options that are either too broad or not relevant to the situation.
Question 7 of 9
What is the mineral necessary for chemical clotting?
Correct Answer: D
Rationale: The correct answer is D: Calcium. Calcium is necessary for the chemical clotting process because it plays a crucial role in the activation of various clotting factors, leading to the formation of a blood clot. Without sufficient calcium, the clotting cascade would not be able to proceed effectively. Iron (choice A) is essential for red blood cell production, not clotting. Potassium (choice B) and Sodium (choice C) are important for various physiological functions but are not directly involved in the clotting process.
Question 8 of 9
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 9 of 9
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
Correct Answer: A
Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.