Questions 9

ATI RN

ATI RN Test Bank

Nursing Process Test Bank Questions

Question 1 of 5

Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?

Correct Answer: D

Rationale: The correct answer is D: Pain related to sickle cell crisis. In a sickle cell crisis, the client experiences severe pain due to the sickling of red blood cells, which causes blockages in blood vessels. This pain is the hallmark symptom of sickle cell crisis and is a priority nursing diagnosis. The other choices are incorrect because they do not directly relate to the primary issue of sickle cell crisis. Imbalanced nutrition is not typically a priority during a crisis, disturbed sleep pattern is not a common symptom, and impaired skin integrity is not a prominent concern in sickle cell crisis.

Question 2 of 5

A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?

Correct Answer: B

Rationale: The correct answer is B: Ask her to demonstrate her ability to ambulate. This response is best because it allows the nurse to assess the patient's actual ability to walk safely to the bathroom. By observing her, the nurse can ensure her safety and prevent potential falls. This approach also respects the patient's autonomy while prioritizing her safety. Incorrect responses: A: Allowing her to ambulate unassisted solely for positive self-esteem overlooks the importance of assessing her actual capability and ensuring safety. C: Explaining that assistance will always be available may not address the immediate need for assessment and safety. D: Asking another staff member to assist without assessing the patient's ability herself does not allow the nurse to directly evaluate the patient's safety and independence.

Question 3 of 5

The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (Hct) in this client?

Correct Answer: B

Rationale: The correct answer is B: Volume overload with hemodilution. In deep partial-thickness burns, there can be fluid shifts leading to volume overload. This excess fluid in the intravascular space can dilute the blood, resulting in a decreased hematocrit (Hct). Reduced Hct indicates lower concentration of red blood cells in the blood. Other choices are incorrect because hypoalbuminemia would lead to hemoconcentration, metabolic acidosis would not directly cause a reduced Hct, and lack of erythropoietin factor would primarily affect erythropoiesis but not directly lead to decreased Hct.

Question 4 of 5

A 45-year-old patient has a long- standing history of allergies to pollen. Which of the following actions indicates that the patient does not understand how to control this disease?

Correct Answer: C

Rationale: The correct answer is C. Driving in the car with the windows open exposes the patient to pollen, worsening allergies. Staying indoors on dry, windy days (A) reduces exposure. Refusing to walk outside in spring (B) also minimizes exposure. Working in the garden on sunny days (D) increases pollen exposure. Therefore, choice C is the only action that goes against controlling pollen allergies.

Question 5 of 5

Which of the ff points should a nurse include in the teaching plan for clients who have potential for hypovolemia?

Correct Answer: A

Rationale: The correct answer is A: Avoid alcohol and caffeine. Alcohol and caffeine are diuretics that can increase urine output, leading to fluid loss and potential hypovolemia. This step is crucial in preventing further dehydration. Summary of incorrect choices: B: Increasing milk and dairy products can contribute to fluid intake but does not address the prevention of hypovolemia. C: While dried peas and beans can provide nutrients, they do not specifically address fluid intake or prevention of hypovolemia. D: Avoiding table salt or sodium-containing foods may help in reducing fluid retention but does not directly address fluid intake to prevent hypovolemia.

Similar Questions

Join Our Community Today!

Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for ATI-RN and 3000+ practice questions to help you pass your ATI-RN exam.

Call to Action Image