ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client’s situation?
Correct Answer: D
Rationale: The correct answer is D: Concept map care plan. This type of care plan allows the nurse to visually represent the client's entire situation, including physical, emotional, and social aspects. By using interconnected concepts and relationships, the nurse can see the whole picture and identify potential interventions. Kardex (A) is a concise patient information summary, not comprehensive. Case management (B) focuses on coordinating services but may not capture the holistic view. Critical pathways (C) outline specific steps in care but may not address the client as a whole.
Question 2 of 5
A post-TURP patient experiences dribbling following removal of his catheter. Which action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Teach him to perform Kegel's exercises 10 to 20 times per hour. This is the appropriate action because Kegel's exercises help strengthen the pelvic floor muscles, which can improve urinary control and reduce dribbling post-TURP. Restricting fluid intake (A) is not necessary and may lead to dehydration. Reinserting the Foley catheter (C) is not recommended as it can increase the risk of infection. Reassuring the patient (D) without providing any intervention is not addressing the issue. Teaching Kegel's exercises is the most effective and non-invasive approach to manage post-TURP dribbling.
Question 3 of 5
A woman with pelvic inflammatory disease complains of lower abdominal pain. Which action should the nurse take first?
Correct Answer: B
Rationale: The correct action is to administer antibiotics as ordered first because pelvic inflammatory disease is caused by an infection, usually from sexually transmitted organisms. Administering antibiotics promptly is crucial to prevent further complications and treat the underlying infection. This helps to alleviate the source of the pain. Rating pain severity, administering analgesics, and patient education are important but should come after addressing the infection to prevent worsening of the condition.
Question 4 of 5
Management of the foregoing patient should include:
Correct Answer: D
Rationale: The correct answer is D because a regular diet with extra fruits and green vegetables can provide essential nutrients for overall health, potassium-sparing diuretics can help manage potassium levels in the body, and discontinuing oral magnesium salts can prevent further complications in the patient. Option A focuses on promoting a healthy diet, B addresses specific medication for potassium management, and C avoids potential interactions with magnesium salts. Therefore, all of the measures (A, B, and C) are necessary for comprehensive management of the patient's condition.
Question 5 of 5
The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording
Correct Answer: C
Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice D) is not as reliable as urinary output for assessing fluid status.