ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
Which laboratory study is monitored for the patient receiving heparin therapy?
Correct Answer: B
Rationale: The correct answer is B: PTT (Partial Thromboplastin Time) because it specifically measures the effectiveness of heparin therapy by assessing the intrinsic pathway of the coagulation cascade. A prolonged PTT indicates that heparin is achieving the desired anticoagulant effect. A: INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin. C: PT (Prothrombin Time) is also used to monitor warfarin therapy. D: Bleeding time is not typically used to monitor heparin therapy and is more focused on platelet function rather than coagulation factors.
Question 2 of 5
An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?
Correct Answer: A
Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results provided.
Question 3 of 5
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Lymphangitis is an inflammation of lymphatic vessels. 2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection. 3. Nurse should notify the physician for further evaluation and treatment. 4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification. 5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification. 6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.
Question 4 of 5
A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
Correct Answer: B
Rationale: The correct answer is B: "Keep the stoma dry." Keeping the stoma dry helps prevent infection and skin irritation. Moisture can lead to fungal growth and skin breakdown. Option A is incorrect because keeping the stoma uncovered can increase the risk of contamination and infection. Option C is incorrect as self-care promotes independence and allows the client to become familiar with the procedure. Option D is incorrect as moisture can lead to skin issues.
Question 5 of 5
The nurse is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make?
Correct Answer: A
Rationale: The correct answer is A because testicular cancer is indeed a highly curable type of cancer if detected early through self-examinations. This empowers the client to take control of their health. Choice B is incorrect as testicular cancer is detectable through self-examinations. Choice C is incorrect as testicular cancer is not the number one cause of cancer deaths in males; it is relatively rare. Choice D is incorrect as testicular cancer is more common in younger men, typically between the ages of 15 and 44.