ATI RN
Nursing Process Exam Questions Questions
Question 1 of 5
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 5
A patient visits her nurse practitioner (NP) after she has a cold for a week and is now experiencing a severe headache and fever. Her NP diagnoses a sinus infection. Which of the following additional symptoms is the patient likely to exhibit?
Correct Answer: A
Rationale: The correct answer is A: Facial tenderness. Sinus infections commonly present with facial tenderness due to the inflammation and pressure within the sinuses. This symptom is often accompanied by pain or pressure around the eyes, cheeks, and forehead. Photophobia (B) is more commonly associated with conditions like migraines or meningitis. Chest pain (C) is not a typical symptom of a sinus infection. Ear drainage (D) is more indicative of an ear infection rather than a sinus infection.
Question 3 of 5
A newly diagnosed patient asks what asthma is. Which of the ff. explanations by the nurse is correct?
Correct Answer: A
Rationale: The correct answer is A because asthma is characterized by inflammation and bronchoconstriction of the airways, leading to difficulty breathing. This explanation accurately describes the pathophysiology of asthma. Explanation for other choices: B: Fluid in the lungs is more indicative of conditions like pneumonia or pulmonary edema, not asthma. C: Asthma involves airway constriction and inflammation, not stretching and non-functionality. D: Asthma is not caused by infection but rather triggered by factors like allergens or irritants.
Question 4 of 5
When administering oxygen to a client, under which of the ff situations should the nurse discontinue the administration and notify the physician?
Correct Answer: C
Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.
Question 5 of 5
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.