ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 9
Which is the most reliable method for monitoring fluid balance?
Correct Answer: A
Rationale: The correct answer is A: Daily intake and output. Monitoring fluid balance involves tracking the amount of fluids taken in and expelled from the body. Intake includes oral, IV, and tube feedings, while output includes urine, vomitus, diarrhea, and any other fluid losses. Daily intake and output provide a comprehensive view of a patient's fluid status, helping identify trends and potential issues. Vital signs (B) provide general information but not specific to fluid balance. Daily weight (C) can fluctuate due to various factors, not just fluid status. Skin turgor (D) is a late sign of dehydration and not as reliable as intake and output monitoring.
Question 2 of 9
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for the patient with a right femur fracture stabilized in a full leg cast is "Acute pain" (Choice C). The rationale for this is as follows: 1. The patient is experiencing moderate discomfort due to the fracture and immobilization in the cast, indicating a need for pain management. 2. Acute pain is a priority in this situation as it can impact the patient's comfort, mobility, and overall recovery. 3. Managing pain effectively is crucial for promoting healing, preventing complications, and improving the patient's quality of life. 4. Posttrauma syndrome (Choice A) may be a consideration in the long term but is not the immediate priority. Constipation (Choice B) is not the most pertinent nursing diagnosis in this scenario. Anxiety (Choice D) may be present but addressing pain is more urgent and directly related to the patient's current condition.
Question 3 of 9
A patient has hand-foot syndrome related to his sickle cell anemia. What findings does the nurse expect to see as the patient is assessed?
Correct Answer: B
Rationale: The correct answer is B: Purplish discoloration of hands and feet. Hand-foot syndrome in sickle cell anemia is characterized by pain, swelling, and purplish discoloration of the hands and feet due to vaso-occlusive crisis. Unequal growth of fingers and toes (A), webbing between fingers and toes (C), and deformities of wrists and ankles (D) are not typical findings associated with hand-foot syndrome in sickle cell anemia.
Question 4 of 9
Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
Correct Answer: A
Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank. Rationale: 1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway. 2. Oxygen tank: To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted. Summary of incorrect choices: B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy. C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation. D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.
Question 5 of 9
The following. items are transported in blood plasma, EXCEPT:
Correct Answer: A
Rationale: The correct answer is A: Oxygen. Oxygen is primarily transported in the blood bound to hemoglobin within red blood cells, not dissolved in plasma. Carbon dioxide is transported in plasma. Nutrients and hormones are also transported in plasma. Therefore, choice A is incorrect as oxygen is not primarily transported in plasma.
Question 6 of 9
A Jewish client has been diagnosed with ulcerative colitis. A nursing diagnosis appropriate for a client who has ulcerative colitis is:
Correct Answer: A
Rationale: The correct answer is A: abdominal pain related to decreased peristalsis. Ulcerative colitis causes inflammation and ulcers in the colon, leading to abdominal pain due to decreased peristalsis. This impairs the movement of stool through the colon, resulting in pain. Choice B is incorrect as diarrhea is a common symptom of ulcerative colitis, not hyperosmolar intestinal contents. Choice C is incorrect as ulcerative colitis often leads to diarrhea and not fluid volume excess. Choice D is incorrect as activity intolerance is not directly related to ulcerative colitis, whereas abdominal pain is a common symptom associated with the condition.
Question 7 of 9
During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
Correct Answer: D
Rationale: The correct answer is D: Kaposi’s sarcoma. In AIDS patients, Kaposi’s sarcoma is a common cancer caused by human herpesvirus 8. It presents as purple or brown skin lesions. Squamous cell carcinoma (A), leukemia (B), and multiple myeloma (C) are not commonly associated with AIDS. Squamous cell carcinoma is linked to sun exposure, leukemia originates in the bone marrow, and multiple myeloma is a cancer of plasma cells. Therefore, the correct answer is D due to its strong association with AIDS.
Question 8 of 9
A client with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
Correct Answer: A
Rationale: The correct answer is A: Vision changes. This is crucial to report immediately because tamoxifen can cause serious eye problems such as retinopathy. Vision changes could indicate a potentially serious adverse reaction that requires prompt medical attention to prevent permanent damage. Headache, hearing loss, and anorexia are not typically associated with tamoxifen use and are less urgent in nature. Reporting vision changes promptly can help prevent irreversible harm and ensure timely intervention.
Question 9 of 9
Blood cells are formed in the:
Correct Answer: C
Rationale: The correct answer is C: Bone marrow. Blood cells are primarily formed in the bone marrow through a process called hematopoiesis. The bone marrow contains stem cells that differentiate into various types of blood cells, including red blood cells, white blood cells, and platelets. Arterioles are small blood vessels that carry blood away from the heart, not involved in blood cell formation. Lymphoid tissue plays a role in immune function but not in blood cell production. Muscle tissue is primarily responsible for movement and does not have a role in blood cell formation. Therefore, the bone marrow is the correct answer as it is the main site of blood cell production in the body.