ATI RN
Nursing Process Exam Questions Questions
Question 1 of 9
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
Correct Answer: A
Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow. Incorrect choices: B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties. C: James’ neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties. D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.
Question 2 of 9
A patient had a lumbar injury. Which neurological test by the nurse would be affected?
Correct Answer: C
Rationale: The correct answer is C: Romberg’s test. Romberg’s test assesses a patient's ability to maintain balance with eyes closed, relying on proprioception from the lower limbs. A lumbar injury can affect proprioception, leading to impaired balance. Rhine’s test evaluates auditory function, not affected by a lumbar injury. Pupillary reaction assesses cranial nerve function, unrelated to a lumbar injury. The patellar reflex is a deep tendon reflex, primarily involving the spinal cord segments L2-L4, not directly affected by a lumbar injury.
Question 3 of 9
A patient has allergic rhinitis. In planning care for the patient, the nurse understands that if the patient does not remain compliant with the treatment regimen, the patient is at risk for developing which of the following?
Correct Answer: A
Rationale: The correct answer is A: Sinusitis. Allergic rhinitis causes inflammation in the nasal passages, leading to congestion and blockage of the sinuses. If the patient does not comply with the treatment regimen, the inflammation can worsen, increasing the risk of developing sinusitis, which is an infection or inflammation of the sinuses. Sinusitis can result in severe pain, pressure, and potentially lead to complications. Summary of other choices: B: Lymphadenopathy - Enlargement of lymph nodes, not directly related to non-compliance with treatment for allergic rhinitis. C: Anaphylaxis - Life-threatening allergic reaction, not a typical consequence of non-compliance with treatment for allergic rhinitis. D: Angioedema - Swelling of deeper layers of skin, usually associated with allergies but not a common outcome of non-compliance with treatment for allergic rhinitis.
Question 4 of 9
A client who underwent litholapaxy surgery for removing bladder stones wants to know how long the urethral catheter needs to stay in place. Which of the ff is the correct response?
Correct Answer: B
Rationale: The correct answer is B: The catheter should remain in place for 1-2 days. After litholapaxy surgery, the urethral catheter is typically removed within 1-2 days to prevent infection and promote healing. Keeping the catheter in place for too long can increase the risk of complications such as urinary tract infections. Options A, C, and D suggest longer durations which are not necessary and may lead to unnecessary discomfort and risks for the client. Therefore, the optimal timeframe for catheter removal post-litholapaxy surgery is within 1-2 days.
Question 5 of 9
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
Correct Answer: D
Rationale: The correct answer is D: Restricting fluids. In SIADH, there is an excess of antidiuretic hormone leading to water retention and dilutional hyponatremia. Restricting fluids helps to prevent further water retention and hyponatremia. Rapid IV fluid infusion (A) worsens the condition by further diluting sodium levels. Administering glucose-containing IV (B) is not directly related to treating SIADH. Encouraging increased oral intake (C) can exacerbate the condition by increasing fluid intake.
Question 6 of 9
Which of the following is an adverse reaction to glipizide (Glucotrol)?
Correct Answer: B
Rationale: The correct answer is B: Hypotension. Glipizide is a sulfonylurea medication used to treat diabetes by lowering blood sugar levels. Hypotension, or low blood pressure, can be an adverse reaction as glipizide may cause vasodilation leading to a drop in blood pressure. Headache (choice A), constipation (choice C), and photosensitivity (choice D) are not common adverse reactions associated with glipizide use. Headache may occur due to other factors, constipation is more commonly associated with opioids, and photosensitivity is typically seen with certain antibiotics or NSAIDs.
Question 7 of 9
Ms. CC’s laboratory values indicate hemoconcentration secondary to fluid loss. Which of the following intravenous solutions would be most appropriate during initial fluid replacement therapy?
Correct Answer: C
Rationale: The correct answer is C: 5% dextrose and water with 60 mEq. This solution is appropriate because it provides both fluid replacement (water) and electrolyte replacement (60 mEq). The dextrose helps prevent hypoglycemia. Choice A is incorrect as 10% dextrose and saline may worsen hemoconcentration. Choice B is not ideal as 5% dextrose and water lacks electrolytes needed for fluid balance. Choice D, distilled water with KCl, is dangerous as it lacks dextrose and may lead to electrolyte imbalances.
Question 8 of 9
A nurse changes a client’s wound dressing according to the protocol outlined by the health care agency. What type of nursing intervention is this?
Correct Answer: C
Rationale: The correct answer is C: Interdependent intervention. This type of nursing intervention involves collaboration with other healthcare professionals to provide holistic care. In this scenario, the nurse is following a protocol set by the health care agency, which likely involves input and guidance from various team members. The nurse's actions require coordination and communication with others to ensure the best outcome for the client. Choice A (Independent intervention) would involve actions that the nurse can perform autonomously without requiring direction from others. Choice B (Dependent intervention) would require an order or prescription from a healthcare provider for the nurse to carry out. Choice D (Collaborative intervention) involves working together with other healthcare professionals on a specific aspect of care, but in this case, the nurse is primarily following a set protocol without necessarily actively collaborating with others during the task.
Question 9 of 9
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
Correct Answer: B
Rationale: The correct answer is B because the client remains radioactive for a period of time after the implant removal, typically around 10 days. During this time, the nurse should take precautions to limit exposure to radiation. Choice A is incorrect because bodily fluids are not highly radioactive, and proper disposal procedures should be followed. Choice C is incorrect as soiled linens should be handled appropriately to prevent contamination. Choice D is incorrect as bed rest may not be necessary, and mobility should be encouraged within safety guidelines.