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
A client is receiving the cell cycle-nonspecific alkylating agent thiotepa (thioplex), 60 mg weekly for 4 weeks by bladder instillation as part of a chemotherapeutic regimen to treat bladder cancer. The client asks the nurse how the drug works. How does thiotepa exert its therapeutic effects?
Correct Answer: C
Rationale: The correct answer is C because thiotepa is a cell cycle-nonspecific alkylating agent that interferes with both DNA replication and RNA transcription. Thiotepa works by cross-linking DNA strands, leading to inhibition of DNA replication and transcription, ultimately causing cell death. This mechanism of action makes it effective against actively dividing cells, such as cancer cells. Choice A is incorrect because thiotepa does not interfere with DNA replication alone. Choice B is incorrect because thiotepa affects both DNA replication and RNA transcription, not just RNA transcription. Choice D is incorrect because thiotepa does not destroy the cell membrane; instead, it acts on the genetic material within the cell.
Question 3 of 9
A patient is admitted to a medical unit with a diagnosis of heart failure. The patient reports that she has had increasing fatigue during the past 2 weeks. Which of the following is the most likely cause of this fatigue?
Correct Answer: B
Rationale: The correct answer is B: Decreased cardiac output. Fatigue in heart failure is primarily due to decreased cardiac output, leading to reduced oxygen and nutrient delivery to tissues, causing fatigue. Dyspnea (A) is shortness of breath, not fatigue. Dry cough (C) is more associated with conditions like pulmonary issues, not fatigue. Orthopnea (D) is difficulty breathing while lying down, not specifically related to fatigue. Hence, decreased cardiac output is the most likely cause of fatigue in this patient.
Question 4 of 9
A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client’s priorities for care using which of the following?
Correct Answer: A
Rationale: The correct answer is A, assessment skills. Assessing the client's current condition, including respiratory status, is crucial in determining priorities for care in asthma management. By utilizing assessment skills, the nurse can gather essential information to identify the client's immediate needs and develop an individualized care plan. Nursing books (B) can provide general information but do not provide real-time data on the client's current status. Client's records (C) may contain historical information but may not reflect the client's current condition. Supervisor's advice (D) is important but should supplement rather than replace the nurse's assessment skills in determining immediate care priorities.
Question 5 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 matches with the "Location" component of the PQRST. This question helps determine the specific area where the pain is occurring, providing crucial information for diagnosis and treatment. This step is important in identifying potential underlying issues related to the pain. Summary of other choices: B: What causes the pain? - This question relates to the "Provocation/Palliation" component, not the location. C: Does it come and go? - This question corresponds to the "Quality" component, focusing on the characteristics of the pain. D: What does the pain feel like? - This question aligns with the "Severity" component, concentrating on the intensity of the pain.
Question 6 of 9
Mr. Boy, a 65-year old man, has been admitted wth severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include:
Correct Answer: B
Rationale: The correct answer is B: a semi-private room. For a burn patient like Mr. Boy, a semi-private room is preferred to provide a more controlled environment for infection prevention, wound care, and privacy. Strict isolation (A) is not necessary as his burns are not infectious. Liberal visiting (C) can increase the risk of infection and compromise his recovery. Sharing equipment (D) can lead to cross-contamination and is not recommended for burn patients. In summary, a semi-private room balances infection control and patient comfort for burn patients.
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 because the "Where is the pain located?" question corresponds to the "P" component in the PQRST assessment, which stands for Provocative/Palliative factors. This question helps identify the specific location of the pain and what triggers or alleviates it. The other choices are incorrect because: - B: "What causes the pain?" corresponds to the "Q" component (Quality of pain), focusing on the characteristics of the pain. - C: "Does it come and go?" corresponds to the "R" component (Region/Radiation of pain), focusing on the pattern and radiation of the pain. - D: "What does the pain feel like?" corresponds to the "S" component (Severity of pain), focusing on the intensity of the pain.
Question 8 of 9
A very popular means of early detection of breast cancer is:
Correct Answer: D
Rationale: The correct answer is D: Breast self-examination. This is because regular breast self-examination allows individuals to become familiar with their own breast tissue and identify any changes or abnormalities early on. X-ray (choice A) and surgical (choice C) are not typically used as early detection methods for breast cancer. Choice B is also incorrect because while mammograms (X-rays) are an important screening tool, self-examination should not be replaced by it, as it is a proactive way for individuals to take charge of their own health.
Question 9 of 9
The nurse is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse plan to use to dilute this medication?
Correct Answer: C
Rationale: The correct answer is C: Normal saline solution. Phenytoin is incompatible with dextrose solutions, so options A and D are incorrect. Lactated Ringer's solution contains calcium, which can interact with phenytoin, leading to precipitation. Therefore, option B is also incorrect. Normal saline is the most compatible diluent for phenytoin, maintaining the drug's stability and effectiveness. It is essential to use the appropriate diluent to prevent adverse reactions or drug interactions.