Which of the following is the appropriate nursing diagnosis?

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Question 1 of 5

Which of the following is the appropriate nursing diagnosis?

Correct Answer: B

Rationale: The correct answer is B, "Fluid volume deficit R/T uncontrolled vomiting." This option correctly identifies the cause of the fluid volume deficit as uncontrolled vomiting, which is a common reason for fluid loss. The nursing diagnosis should always reflect the underlying cause of the issue. A is incorrect as "furrow tongue" is not a recognized medical term related to fluid volume deficit. C is incorrect because dehydration is not typically related to subnormal body temperature unless it is severe. D is incorrect as incessant vomiting is more specific to the cause, but the term "dehydration" should be used instead of "fluid volume deficit" in this context. In summary, option B is the appropriate nursing diagnosis as it accurately links the fluid volume deficit to the cause of uncontrolled vomiting.

Question 2 of 5

A 58-year-old man is diagnosed with cancer of the larynx. Which of the ff. are early symptoms of this cancer?

Correct Answer: D

Rationale: The correct answer is D: Dysphagia or hoarseness. In laryngeal cancer, dysphagia and hoarseness are early symptoms due to vocal cord involvement. Hoarseness results from vocal cord paralysis, while dysphagia occurs when the tumor obstructs the esophagus. Anemia and fatigue (choice A) are nonspecific symptoms seen in various conditions. A noticeable lump in the neck (choice B) typically indicates metastasis to the lymph nodes, which occurs later in laryngeal cancer. Crackles and stridor (choice C) are more associated with respiratory conditions rather than laryngeal cancer.

Question 3 of 5

How many liters per minute of oxygen should be administered to the patient with emphysema?

Correct Answer: A

Rationale: The correct answer is A: 2 L/min. In emphysema, there is impaired gas exchange due to damaged lung tissue, resulting in decreased oxygen levels. Administering too high a flow rate can lead to oxygen toxicity. The standard oxygen therapy for emphysema is 1-2 L/min to maintain oxygen saturation without causing harm. Higher flow rates like 10 L/min (B) and 6 L/min (C) are excessive and can lead to oxygen toxicity. 95 L/min (D) is dangerously high and not suitable for oxygen therapy in emphysema. Therefore, A is the correct choice for safe and effective oxygen administration in emphysema.

Question 4 of 5

Which of the ff is the potential complication the nurse should monitor for when caring for a client with acute respiratory distress syndrome?

Correct Answer: B

Rationale: The correct answer is B: Renal failure. Acute respiratory distress syndrome (ARDS) can lead to hypoxemia and respiratory acidosis, causing decreased perfusion to the kidneys and potentially leading to renal failure. Monitoring for signs of renal failure, such as decreased urine output and elevated creatinine levels, is crucial in managing clients with ARDS. Incorrect choices: A: Chest wall bulging is not a common complication of ARDS. It may be seen in conditions like tension pneumothorax. C: Difficulty swallowing is not a typical complication of ARDS. It may be seen in neurological conditions or esophageal disorders. D: Orthopnea is not a direct complication of ARDS. It is more commonly associated with heart failure or pulmonary edema.

Question 5 of 5

As the nurse collects data on a patient, which of the following is a symptom that may be found that the patient with anaphylaxis may be experiencing?

Correct Answer: D

Rationale: The correct answer is D: Wheezing. Anaphylaxis is a severe allergic reaction that can lead to airway constriction and difficulty breathing, resulting in wheezing. Wheezing is a common symptom of anaphylaxis due to bronchospasm and airway swelling. Dermatitis (A) is a skin reaction, sinusitis (B) is inflammation of the sinuses, and delirium (C) is a state of mental confusion, which are not typical symptoms of anaphylaxis. Wheezing is a critical symptom in anaphylaxis as it indicates potential airway compromise and the need for immediate medical intervention.

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