ATI RN
Nursing Process Questions Questions
Question 1 of 9
Which of the following conditions is suspected?
Correct Answer: A
Rationale: The correct answer is A: Anemia. Anemia is a common condition characterized by a decrease in red blood cells or hemoglobin levels, leading to symptoms like fatigue and weakness. It is often suspected based on symptoms such as pale skin and shortness of breath. Rheumatic arthritis (B) is a type of arthritis affecting joints, not related to the blood. Leukemia (C) is a type of cancer affecting the blood and bone marrow. Systemic Lupus Erythematosus (SLE) (D) is an autoimmune disease that can affect various organs, not specifically related to blood cell levels. Therefore, based on the symptoms described, anemia is the most likely condition to be suspected.
Question 2 of 9
Nurse Raymond is handling a group of student nurses and he is teaching them about fluids and electrolytes. He is correct when he says that a substance moves from an area of higher concentration, this is:
Correct Answer: C
Rationale: Correct Answer: C - Diffusion Rationale: Diffusion is the movement of a substance from an area of higher concentration to an area of lower concentration. This process occurs naturally to achieve equilibrium. In the context of fluids and electrolytes, this movement helps maintain balance within the body. Unlike osmosis, which involves the movement of water molecules across a semi-permeable membrane, diffusion applies to the movement of all types of substances. Filtration involves the movement of substances through a barrier under pressure, and active transport requires energy to move substances against a concentration gradient. Therefore, the correct answer is diffusion as it aligns with the principle of movement from high to low concentration for achieving equilibrium.
Question 3 of 9
Which points should a nurse includes in the discharge teaching plan for a client after cardiac surgery?
Correct Answer: B
Rationale: The correct answer is B because it addresses the importance of notifying the physician about a painless lump at the top of the chest incision, which could indicate a serious complication like a seroma or hematoma. This is crucial for early detection and intervention. A is incorrect because showers are generally allowed after cardiac surgery as long as the incisions are kept clean and dry. C is incorrect because support hose or elastic stockings are typically recommended to be worn during the day and removed at night to prevent swelling and promote circulation. D is incorrect because resuming sexual relations after cardiac surgery should be based on individual recovery and should be discussed with the healthcare provider, rather than a standard timeframe.
Question 4 of 9
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
Correct Answer: C
Rationale: The correct answer is C because respiratory rate is an observable and measurable data point, making it objective. Objective data is factual and observable, such as vital signs. Choices A, B, and D are subjective data as they rely on the patient's perception or interpretation, which can be influenced by various factors and may not always be accurate or reliable. In this case, the nurse can directly measure and document the patient's respiratory rate, making it an objective piece of information.
Question 5 of 9
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. The nurse chose this diagnosis based on the patient's chest x-ray results indicating lower lobe infiltrates, which directly affect gas exchange. Choice A is incorrect because "ineffective breathing pattern" does not specifically address the underlying physiological issue of impaired gas exchange. Choice B is incorrect as it focuses on infection risk from the chest x-ray procedure, not the patient's medical condition. Choice C is incorrect as dehydration is not directly related to pneumonia and infiltrates.
Question 6 of 9
The couple with the lowest risk of having a child with sickle cell disease is the one in which the:
Correct Answer: D
Rationale: The correct answer is D because sickle cell disease is an autosomal recessive genetic disorder. The disease is caused by inheriting two copies of the abnormal hemoglobin gene (HbS). In choice D, the father is HbA (normal) and the mother is HbS (carrier). This combination ensures that the child will inherit one normal gene and one abnormal gene, making them a carrier like the mother but not affected by the disease. Choices A, B, and C all involve at least one parent who carries the HbS gene, increasing the risk of the child having sickle cell disease.
Question 7 of 9
A client is undergoing test for multiple myeloma. Diagnostic study findings in multiple Myeloma includes:
Correct Answer: B
Rationale: The correct answer is B: Bence jones protein in the urine. In multiple myeloma, abnormal plasma cells produce excess monoclonal immunoglobulins, including Bence Jones proteins, which can be detected in the urine. This is a hallmark finding in multiple myeloma diagnosis. A: Incorrect. Serum creatinine levels are typically not affected in multiple myeloma. C: Incorrect. Hypercalcemia, not hypocalcemia, is commonly seen in multiple myeloma due to bone destruction. D: Incorrect. Multiple myeloma often presents with high serum protein levels, not low levels.
Question 8 of 9
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
Correct Answer: C
Rationale: Objective data are measurable and observable facts obtained through physical examination or diagnostic tests. In this case, "Respirations 16" is a quantifiable and observable measurement, making it objective data. It is not influenced by personal interpretation or feelings. The other choices, such as "States 'doesn't feel good'", "Reports a headache", and "Nauseated" are subjective data because they are based on the patient's feelings or experiences, which can vary depending on individual perception and interpretation, making them less reliable for making clinical decisions. By focusing on objective data like "Respirations 16", the nurse can provide a more accurate assessment of the patient's condition.
Question 9 of 9
To monitor the severity of a patient’s heart failure, which of the ff. assessments is the most appropriate for the nurse to include as a daily assessment in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Weight. Monitoring daily weight is crucial in assessing fluid retention and worsening heart failure symptoms. Weight gain can indicate fluid overload, a common complication in heart failure. The other choices (B: Appetite, C: Calorie count, and D: Abdominal girth) are not as directly related to monitoring heart failure severity. Appetite and calorie count may be affected by various factors unrelated to heart failure, while abdominal girth may not provide specific information on fluid status. Monitoring weight allows for early intervention and adjustments in treatment to prevent exacerbation of heart failure symptoms.