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
A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
Correct Answer: B
Rationale: The correct answer is B: Increased urine osmolarity. In hyperglycemia, the body tries to eliminate excess glucose through increased urine output, causing a concentrated urine with high osmolarity. This indicates fluid deficit. Cool, clammy skin (A) may suggest poor perfusion but not fluid volume deficit. Distended neck veins (C) are more indicative of fluid overload. Serum sodium level (D) may be elevated in fluid deficit but does not directly assess volume status like urine osmolarity does.
Question 3 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 4 of 9
Which nursing intervention is most appropriate for a client with multiple myeloma?
Correct Answer: D
Rationale: The correct answer is D: Preventing bone injury. In multiple myeloma, bone lesions are common due to bone destruction by abnormal plasma cells. Preventing bone injury is crucial to avoid fractures and bone pain. This can be achieved through careful handling, fall prevention, and avoiding activities that may increase the risk of bone damage. Monitoring respiratory status (A) is not the priority in multiple myeloma. Balancing rest and activity (B) is important but not as critical as preventing bone injury. Restricting fluid intake (C) is not typically necessary unless there are specific indications like renal issues.
Question 5 of 9
A patient has been prescribed bumetanide (Bumex) every morning for control of hypertension. Which of the ff. statements indicates correct knowledge of the treatment regimen?
Correct Answer: C
Rationale: The correct answer is C: “I’ll take my medication in the morning, every morning.” This statement reflects understanding of the treatment regimen by indicating consistency in taking bumetanide for hypertension control. Taking the medication as prescribed is crucial for its effectiveness in managing blood pressure. Choice A is incorrect because sunbathing all day may not be advisable, especially if the patient is on medication. Choice B is incorrect as it implies no consideration for dietary restrictions that may be necessary with the medication. Choice D is incorrect as stopping medication once blood pressure decreases is not recommended and can lead to rebound hypertension.
Question 6 of 9
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident’s ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct: 1. Assessing respiratory status is crucial during a choking incident to identify if the resident is unable to breathe. 2. In this scenario, the resident's inability to breathe indicates a life-threatening problem requiring immediate intervention. 3. CPR is initiated based on the assessment of the resident's breathing difficulty, emphasizing the critical nature of identifying a life-threatening issue. 4. The assessment of respiratory status directly informs the nurse's actions to address the immediate danger of choking. Summary: - Choice A is correct as assessing respiratory status helps identify life-threatening issues like choking. - Choice B is incorrect as the primary focus is on immediate intervention, not establishing a database. - Choice C is incorrect as the assessment is not for skill practice but for identifying a critical situation. - Choice D is incorrect as the goal is not to facilitate breathing but to address the immediate life-threatening problem.
Question 7 of 9
Which of the following nursing activities is an example of evaluation?
Correct Answer: A
Rationale: The correct answer is A because checking a client's blood pressure after administering medication assesses the effectiveness of the intervention. Evaluation involves determining if the desired outcomes were achieved. Administering oxygen therapy (B) is an implementation task. Developing a plan of care (C) is part of the assessment and planning phase. Teaching about dietary options (D) is part of the implementation phase. In conclusion, only option A involves assessing the outcome of an intervention, making it the correct choice for evaluation.
Question 8 of 9
A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective individual coping related to diabetes mellitus?
Correct Answer: D
Rationale: The correct answer is D because crying whenever diabetes is mentioned indicates emotional distress, a key component of ineffective coping. This response suggests the client is overwhelmed by the diagnosis, affecting their ability to cope effectively. In contrast, choices A, B, and C focus more on physical aspects and management of diabetes, not coping mechanisms. Weight gain could be related to poor diet or medication side effects, skipping insulin doses might indicate non-adherence, and failure to monitor blood glucose could be due to lack of knowledge or resources. Overall, D is the best choice as it directly relates to the client's emotional response to the diagnosis.
Question 9 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 because it involves a comprehensive approach to addressing the patient's concern. By asking the patient about usual sleep patterns and the onset of having difficulty resting, the nurse can gather important information to assess the potential correlation between the leg cast and restless sleep. This approach demonstrates active listening and shows concern for the patient's well-being. Option A is incorrect because it dismisses the patient's concern and does not address the underlying issue. Option B is also incorrect as it focuses solely on documentation without actively addressing the patient's concern. Option C is not the best choice as it delays addressing the patient's immediate need for help with sleeping, which may impact their overall recovery.