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
The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?
Correct Answer: A
Rationale: The correct answer is A because gathering and organizing needed supplies is a crucial step before performing a complex dressing change. By ensuring all necessary supplies are readily available, the nurse can streamline the process, minimize interruptions, and promote efficiency. This step also helps maintain aseptic technique and prevent the spread of infection. Deciding on goals and outcomes (B) is important but typically done as part of the care planning process, not immediately before a dressing change. Assessing the patient's readiness (C) is also important but can be done concurrently with gathering supplies. Calling for assistance (D) may be necessary in some situations, but it is not the immediate step required just before changing the dressing.
Question 3 of 9
Which of the ff. would the nurse explain to the patient is indicated by a Snellen chart finding 20/80?
Correct Answer: B
Rationale: The correct answer is B because a Snellen chart reading of 20/80 means the patient can see at 20 feet what a normal eye can see at 80 feet. This indicates that the patient's vision is below average. Choice A is incorrect because it reverses the numerator and denominator. Choice C is incorrect because it does not accurately represent the Snellen chart findings. Choice D is incorrect because 20/80 is not considered normal vision.
Question 4 of 9
When teaching a client about insulin administration, the nurse should include which instruction?
Correct Answer: D
Rationale: The correct answer is D because drawing up clear insulin first when mixing two types of insulin in one syringe prevents contamination. Clear insulin is drawn up first to avoid clouding from the cloudy insulin. This ensures accurate dosing and prevents potential medication errors. A: Incorrect. Administering insulin after the first meal may lead to hypoglycemia if the client skips or delays meals. B: Incorrect. Insulin should not be injected into the deltoid muscle as it can lead to inconsistent absorption rates. C: Incorrect. Vigorously shaking the insulin vial can cause bubbles, affecting the accuracy of the dose and potentially altering its effectiveness.
Question 5 of 9
As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?
Correct Answer: B
Rationale: The correct answer is B because it indicates a confrontational and possibly disrespectful attitude towards the nurse. This can hinder effective communication and collaboration. A: Shows understanding of hallucinations. C: Demonstrates assistance to the father. D: Reflects consideration for the father's needs. B is incorrect as it does not promote positive interaction.
Question 6 of 9
Mr. Galino is diagnosed to have Raynaud’s disease. Nurse Oliver gives instructions to the client to stop smoking because it causes:
Correct Answer: B
Rationale: The correct answer is B: vasoconstriction, vasospasms. 1. Raynaud's disease involves exaggerated vasoconstriction and vasospasms of blood vessels in response to cold or stress. 2. Smoking aggravates vasoconstriction and vasospasms by constricting blood vessels further. 3. This can worsen symptoms for individuals with Raynaud's disease. 4. Choices A, C, and D do not directly relate to the mechanism of Raynaud's disease and smoking.
Question 7 of 9
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
Correct Answer: A
Rationale: The correct answer is A: Diagnosis. In this scenario, the nurse needs to analyze the data and identify the patient's problem, which is urinary retention due to abnormal kidney function and decreased oral intake. This step is crucial to develop a care plan. Planning (B) comes after diagnosis, where interventions are determined. Implementation (C) involves executing the care plan, and Evaluation (D) is the final step to assess the effectiveness of interventions.
Question 8 of 9
A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?
Correct Answer: D
Rationale: The correct answer is D because a class V finding on a Pap test indicates severe dysplasia or carcinoma in situ, which requires further evaluation through a biopsy to confirm the presence of abnormal cells. This finding is not normal and necessitates immediate action for diagnosis and potential treatment. Choices A, B, and C are incorrect because they do not address the urgency and seriousness of a class V finding, which mandates prompt follow-up to rule out or confirm the presence of precancerous or cancerous cells.
Question 9 of 9
A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity. This is the highest priority as patients with spinal cord injuries are at high risk for pressure ulcers due to immobility. Preventing skin breakdown is crucial to avoid complications. Choices B, C, and D are not as urgent. Choice B may be a concern but preventing skin breakdown takes precedence. Choices C and D are important but not life-threatening like potential skin issues in this patient population.