ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 5
Which of the ff is a sign or symptom characteristic of the later stages of TB?
Correct Answer: C
Rationale: The correct answer is C: Hemoptysis. In the later stages of TB, the infection can lead to damage in the lungs, causing blood to be coughed up (hemoptysis). This is a serious symptom indicating advanced disease progression. Fatigue (A), anorexia (B), and weight loss (D) are common symptoms of TB but can occur in earlier stages as well. Hemoptysis specifically indicates more severe lung involvement, making it characteristic of later stages.
Question 2 of 5
A pregnant client requires immediate but temporary protection from chickenpox. Which type of immunization would be required?
Correct Answer: D
Rationale: The correct answer is D: Passive immunization. This involves administering pre-formed antibodies to provide immediate protection. In the case of a pregnant client needing temporary protection from chickenpox, passive immunization is necessary as it offers immediate immunity without stimulating the client's immune system. - A (Naturally acquired active immunization): This involves exposure to the pathogen and the body producing its antibodies, which takes time and is not suitable for immediate protection. - B (Artificially acquired passive immunization): This option doesn't involve providing pre-formed antibodies, which are needed for immediate protection. - C (Artificially acquired active immunization): This method requires time for the body to develop its immunity, not providing immediate protection as needed in this scenario.
Question 3 of 5
When caring for a patient with AIDS, which of the following nursing actions would be the most appropriate for infection control?
Correct Answer: C
Rationale: The correct answer is C: Wear gloves for blood/body fluid contact. This is the most appropriate action for infection control when caring for a patient with AIDS because HIV is primarily transmitted through blood and certain body fluids. Wearing gloves when coming into contact with blood or body fluids reduces the risk of transmission. Explanation for why other choices are incorrect: A: Wearing gloves at all times may not be necessary and can lead to unnecessary waste of resources. B: Wearing gown and mask at all times is excessive and not indicated unless there is a risk of exposure to blood or body fluids. D: Wearing a mask during patient contact times is not necessary unless there is a risk of exposure to respiratory secretions.
Question 4 of 5
The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:
Correct Answer: C
Rationale: The correct answer is C: Fat. Excessive ingestion of fat has been linked to autoimmunity due to its potential to trigger inflammation in the body, which can disrupt the immune system's balance and lead to autoimmune responses. High-fat diets have been associated with increased production of pro-inflammatory molecules, impacting immune function negatively. Protein (choice A) is essential for immune function, vitamin A (choice B) supports immune responses, and zinc (choice D) is crucial for immune system regulation. However, excessive intake of these nutrients typically does not directly lead to autoimmunity like excessive fat consumption does.
Question 5 of 5
A client with thrombocytopenia secondary to leukemia develops epistaxis. The nurse should instruct the client to:
Correct Answer: B
Rationale: The correct answer is B: Sit upright, leaning slightly forward. This position helps to minimize blood flow to the head, reducing the risk of increased bleeding. It also prevents blood from flowing down the throat, reducing the risk of aspiration. A: Lying supine with the neck extended can increase pressure on the blood vessels in the head, potentially worsening the epistaxis. C: Blowing the nose and putting lateral pressure can disrupt any clots that may have formed and increase bleeding. D: Holding the nose while bending forward at the waist can lead to blood flowing down the throat and increase the risk of aspiration.