ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 9
When the LPN is assisting the patient to use an incentive spirometer, which of the following actions by the patient indicates that the patient needs further teaching on how to use the spirometer?
Correct Answer: D
Rationale: The correct answer is D because exhaling deeply before using the spirometer is incorrect. The purpose of the incentive spirometer is to encourage deep inhalation to improve lung function. Exhaling deeply before using the spirometer goes against this goal and may hinder the effectiveness of the device. Choices A, B, and C are all correct actions when using the spirometer. Taking two normal breaths helps to prepare the lungs, sitting upright optimizes lung expansion, and inhaling deeply to reach the target helps to improve lung ventilation.
Question 2 of 9
The presence of anemia is characterized by a/an:
Correct Answer: C
Rationale: Step-by-step rationale: 1. Anemia is a condition where there is a decrease in the concentration of red blood cells. 2. Red blood cells carry oxygen to the body's tissues, so a decrease in their concentration leads to reduced oxygen delivery. 3. This decrease in red blood cell concentration can be measured through a decrease in hematocrit levels. 4. Choices A and B are incorrect because anemia involves a decrease, not an increase, in red blood cells and hemoglobin. 5. Choice D is incorrect as it mentions "decreased blood count cells," which is not a specific term related to anemia. Summary: The correct answer is C because anemia is characterized by a decrease in the concentration of red blood cells, leading to reduced oxygen delivery, while the other choices are incorrect due to inaccuracies in describing anemia.
Question 3 of 9
A pregnant client requires immediate but temporary protection from chickenpox. Which type of immunization would be required?
Correct Answer: D
Rationale: The correct answer is D: Passive immunization. This involves administering pre-formed antibodies to provide immediate protection. In the case of a pregnant client needing temporary protection from chickenpox, passive immunization is necessary as it offers immediate immunity without stimulating the client's immune system. - A (Naturally acquired active immunization): This involves exposure to the pathogen and the body producing its antibodies, which takes time and is not suitable for immediate protection. - B (Artificially acquired passive immunization): This option doesn't involve providing pre-formed antibodies, which are needed for immediate protection. - C (Artificially acquired active immunization): This method requires time for the body to develop its immunity, not providing immediate protection as needed in this scenario.
Question 4 of 9
A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient’s plan of care?
Correct Answer: C
Rationale: The correct answer is C: Excess fluid volume. This patient is presenting with signs and symptoms of fluid overload, such as weight gain, pitting edema, distended neck veins, and crackles in the lungs. These indicate an excess of fluid in the body. Nursing care for this patient should focus on managing fluid balance. A: Deficient fluid volume is incorrect because the patient is showing signs of fluid overload, not deficit. B: Imbalanced nutrition more than body requirements is incorrect as the symptoms described are related to fluid volume, not nutrition intake. D: Noncompliance is irrelevant to the patient's current symptoms and does not address the underlying issue of fluid overload.
Question 5 of 9
The nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for:
Correct Answer: B
Rationale: The correct answer is B: Pathologic bone fractures. In multiple myeloma, there is an increase in osteoclast activity leading to bone destruction, making patients prone to pathologic fractures. Chronic liver failure (A), acute heart failure (C), and hypoxemia (D) are not directly associated with multiple myeloma pathophysiology. This highlights the importance of understanding the disease process to determine the correct answer.
Question 6 of 9
A client with thrombocytopenia secondary to leukemia develops epistaxis. The nurse should instruct the client to:
Correct Answer: B
Rationale: The correct answer is B: Sit upright, leaning slightly forward. This position helps to minimize blood flow to the head, reducing the risk of increased bleeding. It also prevents blood from flowing down the throat, reducing the risk of aspiration. A: Lying supine with the neck extended can increase pressure on the blood vessels in the head, potentially worsening the epistaxis. C: Blowing the nose and putting lateral pressure can disrupt any clots that may have formed and increase bleeding. D: Holding the nose while bending forward at the waist can lead to blood flowing down the throat and increase the risk of aspiration.
Question 7 of 9
Which of the following nursing actions is appropriate when a patient returns to his or her room after a bronchoscopy?
Correct Answer: D
Rationale: The correct answer is D - Check for a gag reflex before allowing the patient to drink. This is important after a bronchoscopy to prevent aspiration. Step 1: Assessing gag reflex ensures the patient can protect their airway. Step 2: Aspiration risk is high post-bronchoscopy due to sedation and possible throat numbness. Step 3: Allowing fluids without confirming gag reflex can lead to aspiration pneumonia. Other choices are incorrect. A: Ordering a meal immediately is inappropriate after NPO period. B: Encouraging fluids without assessing gag reflex may lead to aspiration. C: Monitoring consciousness is important but not directly related to post-bronchoscopy care.
Question 8 of 9
A patient is being given Digoxin to treat heart failure. Which of the ff. is a usual adult daily dosage of digoxin (Lanoxin)?
Correct Answer: C
Rationale: Rationale: C: 0.25 mg is the correct daily dosage of Digoxin for adults with heart failure. This dosage is within the usual range of 0.125-0.25 mg. It helps improve heart function and manage heart failure symptoms. A: 0.005 mg is too low and ineffective. B: 0.025 mg is also too low for therapeutic effect. D: 2.5 mg is too high and may lead to toxicity in most adult patients.
Question 9 of 9
Before administering a food feeding the nurse knows to perform which of the following assessments/
Correct Answer: A
Rationale: The correct answer is A because assessing the GI tract helps determine the client's readiness for feeding. Bowel sounds indicate gut motility, last BM assesses bowel function, and distention indicates possible issues. Option B is incorrect as it pertains more to neurological assessment. Option C is not a priority assessment before feeding. Option D is incorrect as formula should be warmed to room temperature before feeding to prevent GI upset.