ATI RN
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 best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:
Correct Answer: D
Rationale: The correct answer is D, "Chest and nostrils." This is because observing the movement of the chest and nostrils is the most reliable way to determine if a patient is breathing. The chest rises and falls with each breath, and the nostrils may flare or move as air is inhaled and exhaled. Monitoring these areas provides a direct indication of respiratory effort. Choices A, B, and C are incorrect because they do not directly reflect the act of breathing. Extremities, head, and eyeball movements are not reliable indicators of breathing function.
Question 3 of 5
A client has cancer that has me tastasized to her bones. She is complaining of increased thirst, polyuria and decreased muscle tone. Her lab values are: Na 139mEq/L, k 4 mEq/L, Cl 103 mEq/L, and Ca 8 mg/dl. What electrolyte imbalance is present?
Correct Answer: C
Rationale: The correct answer is C: Hypercalcemia. Increased thirst and polyuria are symptoms of hypercalcemia, as excess calcium can lead to dehydration and increased urine output. Decreased muscle tone is also a common symptom of hypercalcemia. The lab value of Ca 8 mg/dl confirms high levels of calcium in the blood. Incorrect choices: A: Hypocalcemia - This is incorrect as the lab value of Ca 8 mg/dl indicates normal to high levels of calcium, ruling out hypocalcemia. B: Hyperkalemia - This is incorrect as the lab value of K 4 mEq/L is within normal range, ruling out hyperkalemia. D: Hypochloremia - This is incorrect as the lab value of Cl 103 mEq/L is within normal range, ruling out hypochloremia.
Question 4 of 5
A surgical intervention that can cause substantial remission of myasthenia gravis is:
Correct Answer: B
Rationale: The correct answer is B: Thymectomy. The thymus gland is often found to be abnormal in individuals with myasthenia gravis, and removing it through thymectomy can lead to substantial remission of symptoms. This is because the thymus plays a role in the development of the immune system and may be producing antibodies that attack neuromuscular junctions in myasthenia gravis. Choice A, esophagostomy, is a surgical procedure to create an opening in the esophagus for feeding and has no direct impact on myasthenia gravis. Choice C, myomectomy, is the removal of uterine fibroids and is unrelated to myasthenia gravis. Choice D, spleenectomy, is the removal of the spleen and is not a treatment for myasthenia gravis as the spleen is not implicated in the disease process.
Question 5 of 5
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
Correct Answer: D
Rationale: Step 1: Proper positioning helps maintain alignment and prevent deformities in muscles and joints. Step 2: It reduces the risk of contractures by ensuring that Mr. Gabatan's lower extremities are in optimal positions. Step 3: This promotes circulation and reduces pressure on bony prominences. Step 4: Active exercise may exacerbate spasticity, tilt board may not address positioning adequately, and deep massage may not prevent contractures effectively.