ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 9
Which of the ff should a client with auto immune disorder be advised to avoid?
Correct Answer: C
Rationale: The correct answer is C: Being in crowds during the periods of immunosuppression. Clients with autoimmune disorders have compromised immune systems, making them more susceptible to infections. Being in crowds increases the risk of exposure to various pathogens, potentially leading to infections. Avoiding crowds during periods of immunosuppression helps minimize the risk of infections. A: Resting during the periods of severe exacerbation is important for managing symptoms and conserving energy, but it is not specifically related to avoiding triggers for autoimmune disorders. B: Regular exercise during the periods of remission is beneficial for overall health and can help manage autoimmune disorders, as long as it is appropriate and not excessive. D: Humid environments during the periods of remission do not directly impact autoimmune disorders unless the individual has a specific sensitivity to humidity.
Question 2 of 9
Which of the ff nursing interventions would a nurse perform to avoid maceration from irritating drainage or the wound compresses in a client with breast abscess?
Correct Answer: A
Rationale: The correct answer is A: Apply zinc oxide to the surrounding skin. This intervention helps create a protective barrier between the irritating drainage or wound compresses and the skin, thus preventing maceration. Zinc oxide has moisture-repelling properties that can help keep the skin dry and reduce the risk of maceration. Choice B (Using a binder) may not address the root cause of maceration and could potentially increase pressure on the wound site. Choice C (Supporting the arm and shoulder with pillows) may provide comfort but does not directly prevent maceration. Choice D (Instructing the client not to shave axillary hair) is unrelated to preventing maceration from irritating drainage or wound compresses.
Question 3 of 9
Place the following four nursing actions for the new laryngectomee in correct order of priority? i.Assist with ambulation ii.Set up a visit from a well-adjusted laryngectomee iii.Maintain a patent airway iv.Control postoperative pain
Correct Answer: C
Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.
Question 4 of 9
Which of the following is the medication of choice for anaphylaxis that the nurse should anticipate would be ordered?
Correct Answer: A
Rationale: The correct answer is A: Epinephrine. In anaphylaxis, epinephrine is the medication of choice due to its rapid onset of action and ability to reverse severe allergic reactions. It acts by constricting blood vessels, increasing heart rate, and opening airways. This helps counteract the dangerous drop in blood pressure and airway constriction seen in anaphylaxis. Digoxin, theophylline, and furosemide are not appropriate for anaphylaxis as they do not address the immediate life-threatening symptoms of anaphylaxis.
Question 5 of 9
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
Correct Answer: D
Rationale: The correct answer is D: Ask the patient about usual sleep patterns and the onset of having difficulty resting. Rationale: 1. Establish rapport: Asking about usual sleep patterns shows empathy and builds rapport. 2. Holistic assessment: Understanding sleep patterns helps identify potential issues beyond the leg cast. 3. Gather information: Knowing the onset of sleep difficulty can reveal underlying causes. 4. Patient-centered care: Addressing sleep concerns aligns with patient needs. Incorrect answers: A: Focusing solely on the leg and cast disregards the patient's holistic well-being. B: Documenting without addressing the patient's concern neglects the opportunity for intervention. C: Delaying assessment till the next shift can worsen the patient's condition and delay appropriate care.
Question 6 of 9
A patient who is suspected of having hypothyroidism should be expected which of these symptoms?
Correct Answer: D
Rationale: The correct answer is D, extreme fatigue, for a patient suspected of having hypothyroidism. Hypothyroidism is associated with decreased production of thyroid hormones, leading to a slower metabolism and reduced energy levels. This results in symptoms such as fatigue, weakness, and lethargy. Tachycardia (A) is more commonly associated with hyperthyroidism, where the thyroid is overactive. Hyperthermia (B) is increased body temperature, not typically a symptom of hypothyroidism. Weight loss (C) is also more commonly seen in hyperthyroidism due to increased metabolism. In summary, extreme fatigue is a hallmark symptom of hypothyroidism due to decreased thyroid hormone levels, distinguishing it from the other choices.
Question 7 of 9
Which of the following medications can be used to quickly reduce SOB in a crisis situation for a patient with end-stage respiratory disease?
Correct Answer: B
Rationale: Step 1: IV morphine is the correct choice as it is a potent analgesic and has a rapid onset of action to reduce shortness of breath (SOB) in a crisis situation. Step 2: Oral cortisone (A) is not suitable for quick relief of SOB as it has a slower onset of action. Step 3: IM meperidine (C) is an opioid analgesic but not commonly used for managing SOB in end-stage respiratory disease. Step 4: IV propranolol (D) is a beta-blocker and not indicated for immediate relief of SOB in a crisis situation.
Question 8 of 9
Which of the following types of hearing loss does the nurse understand is most improved with the use of a hearing aid?
Correct Answer: C
Rationale: The correct answer is C: Sensorineural hearing loss. Hearing aids are most effective for sensorineural hearing loss as they amplify sound signals to compensate for damage to the inner ear hair cells or auditory nerve. This type of hearing loss is due to problems in the inner ear or auditory nerve, which can be partially compensated for by using hearing aids. The other choices, A: Conductive, B: Mixed, and D: Central, are not as effectively improved by hearing aids. Conductive hearing loss is usually due to problems in the outer or middle ear, which can often be treated with medical or surgical interventions. Mixed hearing loss involves a combination of conductive and sensorineural components, and may require a combination of interventions. Central hearing loss is due to problems in the central auditory pathways in the brain, and is not typically improved by hearing aids.
Question 9 of 9
In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?
Correct Answer: D
Rationale: The correct answer is D, Arcus senilis. This condition does not cause visual problems in the older adult. Arcus senilis is a grayish-white ring around the cornea, which does not affect vision. Glaucoma, macular degeneration, and cataracts are conditions that can lead to visual impairment in older adults. Glaucoma is characterized by increased pressure in the eye, which can damage the optic nerve and lead to vision loss. Macular degeneration affects the central part of the retina, leading to blurred or distorted vision. Cataracts cause clouding of the lens, resulting in decreased vision. Therefore, Arcus senilis is the correct choice as it does not cause visual problems compared to the other conditions listed.