ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
Correct Answer: A
Rationale: Step 1: Orthopnea is a classic symptom of congestive heart failure (CHF) due to fluid accumulation in the lungs when lying flat. Step 2: This symptom occurs because when lying down, the fluid redistributes, making it harder to breathe. Step 3: Fever (choice B) is not typically associated with CHF unless there is an underlying infection. Step 4: Weight loss (choice C) is more indicative of conditions like cancer or malnutrition, not CHF. Step 5: Calf pain (choice D) is more commonly associated with deep vein thrombosis, not CHF. Summary: Orthopnea is the best assessment finding indicating CHF, while the other choices are more likely related to different health conditions.
Question 2 of 5
Mr. Boy, a 65-year old man, has been admitted wth severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include:
Correct Answer: B
Rationale: The correct answer is B: a semi-private room. For a burn patient like Mr. Boy, a semi-private room is preferred to provide a more controlled environment for infection prevention, wound care, and privacy. Strict isolation (A) is not necessary as his burns are not infectious. Liberal visiting (C) can increase the risk of infection and compromise his recovery. Sharing equipment (D) can lead to cross-contamination and is not recommended for burn patients. In summary, a semi-private room balances infection control and patient comfort for burn patients.
Question 3 of 5
The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus?
Correct Answer: A
Rationale: The correct answer is A: antidiuretic hormone (ADH). In diabetes insipidus, there is a deficiency of ADH, which regulates water balance by reducing urine output. Without ADH, excessive urination and thirst occur. FSH, TSH, and LH are not related to water balance regulation. FSH and LH are involved in reproductive functions, while TSH regulates thyroid hormone production. Therefore, the nurse should focus on educating the client about the importance of ADH in managing diabetes insipidus.
Question 4 of 5
A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?
Correct Answer: C
Rationale: Correct Answer: C - Tracheostomy set Rationale: 1. Immediate airway management: After thyroidectomy, there is a risk of airway compromise due to swelling or bleeding. Tracheostomy set ensures immediate access to secure the airway. 2. Emergency intervention: In case of respiratory distress or airway obstruction post-surgery, a tracheostomy set allows for prompt and effective intervention. 3. Patient safety and priority: Ensuring airway patency is crucial for the client's survival and takes precedence over other equipment. Summary of other choices: A: Indwelling urinary catheter kit - Not directly related to post-thyroidectomy care. B: Cardiac monitor - Important but secondary to airway management in this situation. D: Humidifier - Not essential for immediate post-thyroidectomy care.
Question 5 of 5
The nurse knows which of the following is true about immunity?
Correct Answer: C
Rationale: Rationale for Answer C: Antibodies are produced by the B-cells. B-cells are a type of lymphocyte that differentiate into plasma cells, which are responsible for producing antibodies in response to antigens. This process is a key component of the humoral immune response. Therefore, the statement that antibodies are produced by the B-cells is true. Summary of Incorrect Choices: A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity. B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. D: Lymphocytes increasing with an allergic response is not directly related to the production of antibodies by B-cells. Allergic responses involve a different mechanism.