ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 9
Which of the following would indicate that the patient has a normal corneal light reflex?
Correct Answer: D
Rationale: The correct answer is D because a normal corneal light reflex involves light being reflected at the same spot in both eyes. This indicates that both eyes are aligned properly and focusing light in the same direction. Choice A is incorrect because it refers to accommodation, not the corneal light reflex. Choice B is incorrect as convergence is related to eye movement, not the corneal light reflex. Choice C is incorrect as pupil constriction in response to light is known as the pupillary light reflex, not the corneal light reflex.
Question 2 of 9
A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which of the following glands?
Correct Answer: A
Rationale: The correct answer is A: Adrenal cortex. Primary hyperaldosteronism is a condition where the adrenal cortex produces too much aldosterone hormone, leading to hypertension. The adrenal medulla secretes adrenaline and noradrenaline, not aldosterone, making option B incorrect. The pancreas secretes insulin and glucagon, not aldosterone, making option C incorrect. Option D is incorrect because the adrenal cortex is responsible for aldosterone secretion in primary hyperaldosteronism.
Question 3 of 9
The nurse is assessing a client with possible Cushing’s syndrome. In a client with Cushing’s syndrome, the nurse would expect to find:
Correct Answer: C
Rationale: The correct answer is C: deposits of adipose tissue in the trunk and dorsocervical area. In Cushing's syndrome, there is excess cortisol production leading to central obesity with fat accumulation in the trunk and dorsocervical area (buffalo hump). This is due to cortisol's role in redistributing fat. A: hypotension is incorrect because individuals with Cushing's syndrome typically have hypertension due to the effects of excess cortisol on blood pressure regulation. B: thick, coarse skin is incorrect as individuals with Cushing's syndrome may have thin, fragile skin due to decreased collagen formation. D: weight gain in arms and legs is incorrect as the weight gain in Cushing's syndrome tends to be centralized in the trunk and face rather than the extremities.
Question 4 of 9
Wilma knew that James have an adequate respiratory condition if she notices that
Correct Answer: A
Rationale: The correct answer is A because a normal respiratory rate for an adult is typically between 12-20 breaths per minute. A respiratory rate of 18 falls within this range, indicating adequate respiratory function. Choice B is incorrect because an oxygen saturation of 91% is below the normal range of 95-100%, suggesting potential respiratory insufficiency. Choice C is incorrect as frank blood suction from the tube indicates a serious issue such as bleeding, not adequate respiratory condition. Choice D is also incorrect as the presence of a moderate amount of tracheobronchial secretions may indicate a respiratory infection or other respiratory issue, not necessarily adequate respiratory condition.
Question 5 of 9
A young male client visits a nurse with a complaint of chronic tension headaches. Which of the ff is the most appropriate nursing instruction to manage the client?
Correct Answer: C
Rationale: The correct answer is C: Counselling on alternate therapies. Chronic tension headaches may be exacerbated by stress or other psychological factors, making counseling an appropriate intervention. The nurse can explore relaxation techniques, stress management strategies, or cognitive-behavioral therapy to help the client manage their headaches. A: Instructing the client to monitor for signs of bruising or bleeding is unrelated to tension headaches and not a priority in this situation. B: Suggesting eating and swallowing techniques that reduce the potential for aspiration is not relevant to tension headaches and is not the most appropriate intervention. D: Advising the client to change sleeping positions frequently may help with other types of headaches but is not the most effective strategy for managing chronic tension headaches.
Question 6 of 9
An adult has a central line in his right subclavian vein. The nurse is to change the tubing. Which of the following should be done?
Correct Answer: C
Rationale: The correct answer is C: Close the roller clamp on the new tubing after priming it. This step ensures that the tubing is primed with the solution and ready for use while preventing air from entering the central line. Option A is incorrect because using the present solution may introduce contamination. Option B is incorrect as connecting tubing before running fluid can introduce air into the line. Option D is incorrect as positioning the client on the right side does not prevent air embolism during tubing change.
Question 7 of 9
The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
Correct Answer: D
Rationale: The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions." Rationale: 1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being. 2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery. 3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient. 4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes. Summary: A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs. B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses. C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.
Question 8 of 9
Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?
Correct Answer: D
Rationale: The correct answer is D because using two pillows to raise the head can increase the risk of venous stasis and thrombosis in a client with polycythemia vera. This condition involves an increased production of red blood cells, leading to thicker blood and potential clot formation. Elevating the head too much can impede blood flow, exacerbating the risk of clotting. Choices A, B, and C are all appropriate statements indicating good self-care practices and physical activity, which are beneficial for clients with polycythemia vera to improve circulation and overall health.
Question 9 of 9
Which of the following nursing interventions is appropriate after a lumbar puncture?
Correct Answer: A
Rationale: The correct answer is A: Have the patient lie flat for 6 to 8 hours after a lumbar puncture to prevent complications like post-lumbar puncture headache. Lying flat helps maintain CSF pressure and reduce the risk of leakage. B: Keeping the patient from eating or drinking for 4 hours is not necessary after a lumbar puncture. C: Monitoring pedal pulses q4h is irrelevant to post-lumbar puncture care. D: Keeping the head of the bed elevated 30 degrees for 24 hours is not recommended after a lumbar puncture as it may increase the risk of complications.