ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 9
Which of the ff symptoms should a nurse assess in a client when implementing interventions for trauma to the upper airway?
Correct Answer: D
Rationale: The correct answer is D: Presence of laryngospasm. Laryngospasm is a serious complication of trauma to the upper airway that can lead to airway obstruction. Assessing for laryngospasm is crucial to ensure the client's airway remains patent. Pain when talking (A) is more related to vocal cord injury, increased nasal swelling (B) is a symptom of nasal trauma, and burning in the throat (C) may indicate pharyngeal injury, but laryngospasm (D) directly affects airway patency in upper airway trauma cases.
Question 2 of 9
A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Equipment. The nurse needs to ensure that necessary equipment is available to carry out interventions effectively and safely. Without the right equipment, the nurse may not be able to provide appropriate care. Safe environment (B) is important but not a resource that the nurse makes sure is available. Confidence (C) is a personal attribute and not a resource. Assistive personnel (D) are individuals who can help but are not resources that the nurse ensures are available.
Question 3 of 9
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
Correct Answer: C
Rationale: The correct answer is C because it is essential for the nurse to ensure accurate and up-to-date vital signs before administering medications. By asking the NAP to record the patient's vital signs, the nurse can make informed decisions about the patient's condition and prevent any potential complications. Choice A is incorrect because administering medications without knowing the patient's vital signs, particularly if they are abnormal, can be dangerous. Choice B is not the best course of action as it delays the crucial step of obtaining the vital signs. Choice D is incorrect as omitting vital signs without assessment could compromise patient safety. Therefore, choice C is the most appropriate response to ensure patient well-being and medication safety.
Question 4 of 9
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
Correct Answer: A
Rationale: The correct answer is A: Platelet count, prothrombin time, and partial thromboplastin time. These parameters are essential in monitoring DIC because platelet count reflects the risk of bleeding, while prolonged prothrombin time and partial thromboplastin time indicate impaired clotting function, which is characteristic of DIC. Explanation for why other choices are incorrect: - Choice B: Blood glucose levels and WBC count are not specific indicators for DIC monitoring. - Choice C: Thrombin time, calcium levels, and potassium levels do not directly assess clotting abnormalities associated with DIC. - Choice D: While fibrinogen level is important in DIC, WBC count alone is not a specific indicator for monitoring DIC.
Question 5 of 9
A nurse conducts an assessment and notes that the client has abnormal breath sounds, a productive cough, and cyanotic lips. How should the nurse categorize these findings?
Correct Answer: B
Rationale: The correct answer is B: Objective data. Abnormal breath sounds, a productive cough, and cyanotic lips are all observable and measurable findings that can be verified by the nurse through assessment. Objective data refers to information that can be observed or measured, providing concrete evidence of the client's condition. In this case, the nurse directly perceives these physical signs during the assessment, making them objective data. Summary: - A: Subjective data involves the client's feelings or opinions, which are not directly observable by the nurse. - C: Secondary data are information obtained from other sources, not directly from the client. - D: Primary data are firsthand information collected directly from the client, but in this scenario, the findings are observable physical signs, making them objective data.
Question 6 of 9
Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
Correct Answer: B
Rationale: The correct answer is B: Acute pain. The rationale is that NANDA-I (North American Nursing Diagnosis Association-International) approves nursing diagnoses that are specific, measurable, and relevant to nursing care. Acute pain fits these criteria as it is a common nursing diagnosis that can be assessed objectively and treated with nursing interventions. The other choices (sore throat, sleep apnea, heart failure) are medical diagnoses that do not fall under the scope of nursing diagnoses approved by NANDA-I. Therefore, acute pain is the most appropriate diagnosis to be documented in a patient's care plan according to NANDA-I guidelines.
Question 7 of 9
A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?
Correct Answer: D
Rationale: The correct initial action to take after the patient falls is to assess the patient (Choice D). This is important to determine the extent of any injuries sustained, assess the patient's current condition, and identify any factors that may have contributed to the fall. By conducting a thorough assessment, the nurse can gather crucial information to inform the revision of the care plan. Consulting physical therapy (Choice A) may be necessary later on but is not the immediate priority. Establishing a new plan of care (Choice B) and setting new priorities (Choice C) should be based on the assessment findings, making Choice D the most appropriate initial action.
Question 8 of 9
Which of the following types of cells is the immune system’s shutoff mechanism?
Correct Answer: B
Rationale: The correct answer is B: Suppressor T cells. Suppressor T cells regulate the immune response by inhibiting the activity of other immune cells to prevent overreaction and maintain immune balance. They play a crucial role in preventing autoimmune diseases and excessive inflammation. Plasma cells (A) produce antibodies, Helper T cells (C) assist in activating other immune cells, and B lymphocytes (D) are involved in antibody production. Suppressor T cells specifically have the function of shutting down immune responses, making them the immune system’s shutoff mechanism.
Question 9 of 9
Many neuromuscular disorders can impair respiratory function. What intervention can a home care nurse recommend to help prevent complications in patients with impaired respiratory function?
Correct Answer: C
Rationale: The correct answer is C: Elevate the head of bed. Elevating the head of the bed helps improve lung expansion and ventilation, making it easier for patients with impaired respiratory function to breathe. This position also helps prevent aspiration and reduces the risk of respiratory complications. Antibiotics (choice A) are not indicated unless specifically prescribed for an infection. Bedrest (choice B) can lead to deconditioning and worsen respiratory function. Suctioning (choice D) every 4 hours is not necessary unless there is excessive secretions present.