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
Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
Correct Answer: C
Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease. Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites. Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites. Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.
Question 3 of 9
A 50-year-old African American patient is diagnosed with anemia. Where can the nurse assess for pallor?
Correct Answer: D
Rationale: The correct answer is D: Conjunctivae. Pallor is best assessed in the conjunctivae due to the transparent nature of the tissue, allowing for easy observation of paleness. The conjunctivae are the mucous membranes lining the inner surface of the eyelids and covering the sclera. Anemia can cause decreased hemoglobin levels, resulting in paleness of the mucous membranes. Assessing the scalp (A), chest (B), or axillae (C) may not provide a clear indication of pallor related to anemia. The conjunctivae offer a direct and reliable site to assess for pallor in patients with anemia.
Question 4 of 9
The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
Correct Answer: A
Rationale: The correct answer is A: Administer the acetaminophen. The rationale is as follows: 1. The patient has a standing order for acetaminjson for headache relief. 2. The nurse has assessed that the patient needs headache relief and has not had the medication in the past 4 hours. 3. Administering the acetaminophen aligns with the prescribed treatment plan and the patient's needs. Summary: - Option B is incorrect because obtaining a verbal order is not necessary when there is a standing order. - Option C is incorrect as nursing assistive personnel should not administer medications without direct supervision. - Option D is incorrect as pain assessment should precede medication administration to ensure appropriateness.
Question 5 of 9
What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?
Correct Answer: A
Rationale: The correct size of suction catheter for James would be Fr. 5. The selection of suction catheter size is based on the patient's height and weight, as well as the secretions to be cleared. A Fr. 5 catheter is appropriate for an average adult like James, as it balances between being too small or too large. Fr. 12 and Fr. 18 are too large for his size and could cause trauma, while Fr. 10 is slightly larger than needed, increasing the risk of mucosal damage. Therefore, Fr. 5 is the most suitable choice for James.
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
When a neurologist asks a patient to smile, which cranial nerve is being tested?
Correct Answer: C
Rationale: Step-by-step rationale: 1. The cranial nerve responsible for facial expression is CN VII, the facial nerve. 2. When a neurologist asks a patient to smile, they are testing the function of CN VII. 3. CN II (optic nerve) is responsible for vision, not facial expression. 4. CN X (vagus nerve) is responsible for various functions like heart rate and digestion, not facial expression. 5. CN XI (accessory nerve) is responsible for shoulder movement, not facial expression. Summary: Testing a patient's ability to smile involves assessing the function of CN VII, the facial nerve. Choices A, B, and D are incorrect as they are associated with different functions and not responsible for controlling facial muscles.
Question 8 of 9
A client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?
Correct Answer: D
Rationale: The correct answer is D: Sigmoidoscopy. Sigmoidoscopy is a direct visualization procedure that allows for examination of the lower part of the colon and rectum, where colorectal cancer commonly occurs. This procedure can help identify any abnormal growths or polyps that may indicate cancer. Stool hematest (A) detects blood in stool but does not confirm colorectal cancer. Abdominal CT (B) provides imaging of the abdomen but may not definitively diagnose colorectal cancer. CEA scan (C) measures a tumor marker associated with colorectal cancer but is not a definitive diagnostic test. Thus, sigmoidoscopy is the most appropriate diagnostic study for confirming colorectal cancer.
Question 9 of 9
The nurse is caring for a patient with HIV. Which of the following foods would the nurse teach the patient is safe to eat to reduce the risk of infection?
Correct Answer: C
Rationale: The correct answer is C: Cooked vegetables. Cooking vegetables helps to kill harmful bacteria and parasites that may pose a risk of infection to an immunocompromised individual like a patient with HIV. Raw fruits (A) and raw vegetables (B) may carry pathogens that can be dangerous for someone with a weakened immune system. Caesar dressing (D) may contain raw eggs, which also pose a risk for infection. Therefore, choosing cooked vegetables is the safest option to reduce the risk of infection for the patient with HIV.