ATI RN
Nursing Process Questions Questions
Question 1 of 9
Which of the following explanations by the nurse will help a patient understand what to expect during a bronchoscopy?
Correct Answer: A
Rationale: The correct answer is A because it accurately describes the procedure of bronchoscopy. The nurse's explanation should focus on the insertion of a small tube through the nose or mouth into the bronchi to visualize the airways. This information helps the patient understand the basic process and what to expect during the procedure. Choice B is incorrect as bronchoscopy does not involve breathing a radioactive substance to show diseased areas in the lungs. Choice C is also incorrect as there is no requirement to drink a thick white liquid for bronchoscopy. Choice D is incorrect as dye injection is not a standard part of bronchoscopy, and asking about allergies to dye is irrelevant in this context.
Question 2 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 3 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 4 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 as it directly addresses the underlying physiological issue of impaired gas exchange due to alveolar-capillary membrane changes. The infiltrates indicate infection and inflammation in the lower lobes, leading to difficulty in oxygen and carbon dioxide exchange. This diagnosis aligns with the patient's medical condition and helps guide nursing interventions focused on improving oxygenation. Choice A is incorrect because ineffective breathing pattern is a broad diagnosis that does not specifically address the gas exchange issue seen in pneumonia. Choice B is incorrect as the risk for infection is already present with the diagnosis of pneumonia and does not directly address the patient's current respiratory status. Choice C is incorrect as dehydration is not the primary concern in a patient with pneumonia and lower lobe infiltrates.
Question 5 of 9
. Which of the following laboratory test results would suggest to the nurse that a client has a corticotrophin- secreting pituitary adenoma?
Correct Answer: B
Rationale: Step-by-step rationale: 1. Corticotropin-secreting pituitary adenoma leads to excess adrenocorticotropic hormone (ACTH) production. 2. High corticotropin levels would be expected due to the adenoma's overproduction. 3. The high cortisol levels occur as a result of increased ACTH stimulating cortisol release from the adrenal glands. 4. Therefore, choice B (high corticotropin and high cortisol levels) is the correct answer. Summary: - Choice A is incorrect because low cortisol levels would not be expected in a client with a corticotrophin-secreting pituitary adenoma. - Choice C is incorrect because low corticotropin levels would not align with the excessive ACTH production from the adenoma. - Choice D is incorrect as both low corticotropin and low cortisol levels would not be consistent with the pathophysiology of a corticotrophin-secreting pituitary adenoma.
Question 6 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 is the most appropriate nursing diagnosis for a patient with pneumonia and lower lobe infiltrates. The rationale is that pneumonia causes inflammation and fluid accumulation in the alveoli, impairing the exchange of oxygen and carbon dioxide in the lungs. This directly affects gas exchange. Choice A is incorrect because ineffective breathing pattern is a broad nursing diagnosis that does not specifically address the underlying issue of impaired gas exchange in pneumonia. Choice B is incorrect as the risk of infection related to the chest x-ray procedure is unrelated to the patient's current condition of pneumonia. Choice C is also incorrect as dehydration does not directly correlate with the patient's diagnosis of pneumonia and lower lobe infiltrates.
Question 7 of 9
The physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result confirms SLE?
Correct Answer: B
Rationale: The correct answer is B: An above-normal anti-deoxyribonucleic acid. In SLE, the body produces antibodies against its own DNA, leading to the presence of anti-dsDNA antibodies. Elevated levels of anti-dsDNA antibodies are specific to SLE, confirming the diagnosis. A: Increased total serum complement levels are seen in SLE due to complement activation but are not specific to SLE. C: Negative antinuclear antibody test is not consistent with SLE, as ANA positivity is common in SLE. D: Negative lupus erythematosus cell test is not specific to SLE as lupus erythematosus cells are not always present.
Question 8 of 9
Choose the condition that exhibits blood values with a low pH and a high PCO :
Correct Answer: A
Rationale: Correct Answer: A: Respiratory acidosis Rationale: 1. Respiratory acidosis is caused by inadequate ventilation leading to increased PCO₂ and decreased pH. 2. Low pH indicates acidosis, and high PCO₂ indicates respiratory component. 3. Metabolic acidosis (B) results from non-respiratory causes. 4. Respiratory alkalosis (C) is characterized by high pH and low PCO₂. 5. Metabolic alkalosis (D) is caused by non-respiratory factors with high pH.
Question 9 of 9
The spouse of a client with gastric cancer expresses concern that the couple’s children may develop this type of cancer when they’re older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
Correct Answer: A
Rationale: Step 1: Type A blood has been associated with a slightly higher risk of developing gastric cancer compared to other blood types. Step 2: The nurse mentioned a 10% increase in risk, which aligns with the increased risk associated with Type A blood. Step 3: Type AB and Type B blood do not have the same increased risk for gastric cancer as Type A blood. Step 4: Type O blood is actually associated with a lower risk of gastric cancer compared to Type A blood. Step 5: Therefore, the correct answer is A: Type A blood.