ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
Which of the following is an intraoperative outcome for a patient undergoing an inguinal hernia repair?
Correct Answer: C
Rationale: The correct answer is C: Maintains skin integrity. During inguinal hernia repair surgery, maintaining skin integrity is crucial to prevent infection and ensure proper wound healing. This outcome focuses on the physical aspect of the surgery and reflects the patient's skin condition postoperatively. Verbalizing fears (A) addresses emotional concerns, demonstrating leg exercises (B) is related to postoperative rehabilitation, and explaining deep breathing exercises (D) targets respiratory function, none of which directly assess the intraoperative outcome of skin integrity.
Question 2 of 5
Which of the ff should the nurse identify as the earliest symptom of heart failure in many older clients?
Correct Answer: B
Rationale: The correct answer is B: Dyspnea on exertion. In older clients, dyspnea on exertion is often the earliest symptom of heart failure due to decreased cardiac reserve. This occurs when the heart cannot pump enough blood to meet the body's demands during physical activity. Increased urine output (A) is not typically an early symptom of heart failure. Swollen joints (C) are more indicative of arthritis or inflammation, not necessarily heart failure. Nausea and vomiting (D) are not typical early symptoms of heart failure and are more commonly associated with gastrointestinal issues.
Question 3 of 5
Which of the ff. nursing diagnoses is the focus of care for a patient with hypertension?
Correct Answer: D
Rationale: The correct answer is D: Deficient knowledge. This nursing diagnosis is appropriate because educating the patient about hypertension, its management, lifestyle modifications, and medication adherence is crucial in improving outcomes. Activity intolerance (A) and impaired physical mobility (B) are not typically primary focuses for hypertension but may be secondary concerns. Ineffective airway clearance (C) is unrelated to hypertension. Therefore, D is the most relevant option for addressing the patient's needs.
Question 4 of 5
A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?
Correct Answer: B
Rationale: The correct answer is B: Ask her to demonstrate her ability to ambulate. This response is best because it allows the nurse to assess the patient's actual ability to walk safely to the bathroom. By observing her, the nurse can ensure her safety and prevent potential falls. This approach also respects the patient's autonomy while prioritizing her safety. Incorrect responses: A: Allowing her to ambulate unassisted solely for positive self-esteem overlooks the importance of assessing her actual capability and ensuring safety. C: Explaining that assistance will always be available may not address the immediate need for assessment and safety. D: Asking another staff member to assist without assessing the patient's ability herself does not allow the nurse to directly evaluate the patient's safety and independence.
Question 5 of 5
Seven girls were victims of food poisoning after eating the sandwiches served at snack time. Which of the following statement are true regarding food poisoning?
Correct Answer: D
Rationale: Step 1: Symptoms of food poisoning typically include salivation, cramping, nausea, vomiting, and diarrhea, so statement A is correct. Step 2: Food left unrefrigerated can lead to bacterial growth, making it more dangerous, so statement B is accurate. Step 3: Cooking can kill harmful organisms and stop the production of toxins, supporting statement C. Step 4: All three statements are true and collectively provide a comprehensive understanding of food poisoning, making option D the correct answer.