Questions 9

ATI RN

ATI RN Test Bank

Nursing Process NCLEX Questions Questions

Question 1 of 5

Which of the ff is a nursing intervention when assessing clients with hypertension?

Correct Answer: B

Rationale: The correct answer is B because teaching the client about both non-pharmacologic and pharmacologic methods for managing hypertension is a crucial nursing intervention to empower the client in their self-care and treatment plan. This intervention helps the client understand the importance of lifestyle modifications and medication adherence in controlling blood pressure. A: The nurse taking the temperature in different positions is not directly related to assessing hypertension. C: Taking BP in different positions is important for orthostatic hypotension, not specifically for hypertension. D: Weighing the client each morning is not a direct nursing intervention for assessing hypertension.

Question 2 of 5

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Correct Answer: A

Rationale: The correct answer is A because during the first phase of the nursing process (assessment), the nurse gathers a comprehensive database of information about the patient's health status. This step is crucial for identifying the patient's needs and developing a holistic care plan. Choice B is incorrect because identifying nursing diagnoses typically occurs in the second phase (diagnosis). Choice C is incorrect as intervening based on care priorities happens in the third phase (planning and implementation). Choice D is incorrect as determining outcomes achieved is part of the final phase (evaluation).

Question 3 of 5

A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)

Correct Answer: C

Rationale: The correct answer is C because Nursing Outcomes Classification adds objectivity to judging a patient's progress by providing standardized criteria for assessing outcomes. This helps in evaluating the effectiveness of interventions and tracking improvements accurately. Other choices are incorrect: A is wrong because Nursing Outcomes Classification includes 7 domains but not necessarily for level 1; B is incorrect as it uses a 5-point Likert scale, not a 3-point scale; and D is inaccurate because Nursing Outcomes Classification guides the selection of interventions based on the identified outcomes, not allowing complete freedom in choosing interventions.

Question 4 of 5

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?

Correct Answer: C

Rationale: Rationale: 1. Anemia results in decreased oxygen-carrying capacity, leading to tissue hypoxia. 2. Dyspnea (shortness of breath) occurs due to the body's attempt to increase oxygen intake. 3. Tachycardia (rapid heart rate) compensates for decreased oxygen delivery. 4. Pallor (pale skin) is a classic sign of decreased red blood cells in iron-deficiency anemia. Summary: A: Night sweats, weight loss, and diarrhea are not typical manifestations of iron-deficiency anemia. B: Nausea, vomiting, and anorexia are non-specific symptoms and not specific to iron-deficiency anemia. D: Itching, rash, and jaundice are not commonly associated with iron-deficiency anemia.

Question 5 of 5

A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client’s urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?

Correct Answer: D

Rationale: The correct answer is D: Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large volumes of dilute urine. This results in low urine osmolality as the kidneys are unable to concentrate the urine. On the other hand, the serum osmolality increases due to the lack of ADH causing water retention. Therefore, the laboratory findings of low urine osmolality and high serum osmolality support the diagnosis of diabetes insipidus. Explanation for other choices: A: Above-normal urine and serum osmolality levels - This does not align with the pathophysiology of diabetes insipidus. B: Below-normal urine and serum osmolality levels - This is incorrect as low serum osmolality is not characteristic of diabetes insipidus. C: Above-normal urine osmolality level, below-normal

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