ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 9
Which of the following lab value profiles should the nurse know to be consistent with hemolytic anemia?
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer (A): 1. Increased RBC: Hemolytic anemia leads to increased RBC production as the body compensates for the destruction of red blood cells. 2. Decreased bilirubin: Bilirubin levels decrease due to the accelerated breakdown of red blood cells. 3. Decreased Hgb and Hct: Hemolysis causes a decrease in hemoglobin and hematocrit levels as red blood cells are destroyed. 4. Increased reticulocytes: Reticulocytes are immature red blood cells released by the bone marrow in response to increased RBC destruction. Summary: - Choice B is incorrect as hemolytic anemia would lead to increased, not decreased, bilirubin levels. - Choice C is incorrect as hemolytic anemia would lead to decreased, not increased, Hgb and Hct levels. - Choice D is incorrect as hemolytic anemia would not lead to increased levels of all parameters
Question 2 of 9
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Correct Answer: A
Rationale: The correct answer is A because during the first phase of the nursing process (assessment), the nurse collects a comprehensive database of information about the patient's health status and needs. This data forms the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Choices B, C, and D involve actions that occur in the subsequent phases of the nursing process (diagnosis, planning, and evaluation), not in the initial assessment phase. Therefore, A is the correct choice for the first phase.
Question 3 of 9
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Correct Answer: A
Rationale: The correct answer is A because the first phase of the nursing process is assessment, where the nurse gathers comprehensive data about the patient's health status. This step is crucial in identifying problems and setting priorities for care. Choice B comes in the second phase (diagnosis), C in the third phase (planning), and D in the last phase (evaluation). Assessing the patient's condition is the foundation for the rest of the nursing process.
Question 4 of 9
A client has cancer that has me tastasized to her bones. She is complaining of increased thirst, polyuria and decreased muscle tone. Her lab values are: Na 139mEq/L, k 4 mEq/L, Cl 103 mEq/L, and Ca 8 mg/dl. What electrolyte imbalance is present?
Correct Answer: C
Rationale: The correct answer is C: Hypercalcemia. Increased thirst and polyuria are symptoms of hypercalcemia, as excess calcium can lead to dehydration and increased urine output. Decreased muscle tone is also a common symptom of hypercalcemia. The lab value of Ca 8 mg/dl confirms high levels of calcium in the blood. Incorrect choices: A: Hypocalcemia - This is incorrect as the lab value of Ca 8 mg/dl indicates normal to high levels of calcium, ruling out hypocalcemia. B: Hyperkalemia - This is incorrect as the lab value of K 4 mEq/L is within normal range, ruling out hyperkalemia. D: Hypochloremia - This is incorrect as the lab value of Cl 103 mEq/L is within normal range, ruling out hypochloremia.
Question 5 of 9
The lungs regulate acid-base balance b₃y⁻ all of the following except:
Correct Answer: C
Rationale: The correct answer is C: Slowing ventilation. The lungs regulate acid-base balance by controlling carbon dioxide levels through ventilation. Increasing ventilation helps expel excess carbon dioxide, thus regulating pH. Slowing ventilation would lead to CO2 buildup and an imbalance in acid-base levels. Excreting HCO3- into the blood (choice A) helps maintain pH, while increasing ventilation (choice D) aids in removing excess CO2. Therefore, slowing ventilation is the exception as it would disrupt the acid-base balance by not effectively regulating carbon dioxide levels.
Question 6 of 9
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct: 1. Blood pressure is vital in this scenario due to prednisone discontinuation. 2. Abruptly stopping prednisone can lead to adrenal insufficiency. 3. Adrenal insufficiency can cause hypotension, a life-threatening condition. 4. Monitoring blood pressure can help detect and manage potential complications. Summary of other choices: A: Breath sounds – Important but not the priority in this specific situation. C: Capillary refill – Useful for assessing circulation but not urgent in this context. D: Butterfly rash – A characteristic of lupus, but not a critical concern in this scenario.
Question 7 of 9
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? This question corresponds to the "P" in PQRST, which stands for Provocation/Palliation. By asking where the pain is located, the nurse is gathering information about what triggers or relieves the pain, aiding in the assessment of the chest pain. The other choices are incorrect because: B: What causes the pain? - This question corresponds to the "Q" in PQRST, which stands for Quality. It focuses on understanding the characteristics of the pain, not the cause. C: Does it come and go? - This question corresponds to the "R" in PQRST, which stands for Radiation. It pertains to whether the pain spreads to other areas, not if it comes and goes. D: What does the pain feel like? - This question corresponds to the "S" in PQRST, which stands for Severity. It relates to the intensity of the pain, not its location.
Question 8 of 9
The activation of B cells in humoral immunity is assisted by which of the following?
Correct Answer: C
Rationale: The correct answer is C: Helper T cells. Helper T cells play a crucial role in activating B cells by releasing cytokines that stimulate B cell proliferation and differentiation. They also help in the production of antibodies. Cytotoxic T cells (A) are involved in cell-mediated immunity, not humoral immunity. Suppressor T cells (B) regulate the immune response and do not directly assist in B cell activation. Neutrophils (D) are phagocytic cells involved in innate immunity, not in activating B cells in humoral immunity.
Question 9 of 9
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? In the PQRST mnemonic, "P" stands for provocation, "Q" for quality, "R" for region/radiation, "S" for severity, and "T" for timing. The question "Where is the pain located?" corresponds to the "R" component, which is region/radiation. This question helps the nurse identify the specific area where the pain is localized, which can provide valuable information for diagnosis. Explanation of other choices: B: What causes the pain? This question relates more to the "P" component, which is provocation, rather than the region/radiation aspect. C: Does it come and go? This question pertains to the "T" component, which is timing, focusing on the pattern of the pain rather than the specific location. D: What does the pain feel like? This question is more aligned with the "Q" component, which is quality,