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
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 3 of 9
An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first?
Correct Answer: A
Rationale: The correct answer is A: The client’s airway should be assessed first. This is because airway management is the top priority in any emergency situation to ensure the patient can breathe. Without a patent airway, the patient's oxygenation and ventilation will be compromised, leading to serious complications or death. Choices B, C, and D are incorrect because assessing the airway takes precedence over determining the reason for admission, reviewing medications, or assessing past medical history in an unconscious patient. These other assessments are important but not as critical as securing the airway to maintain the patient's breathing and oxygenation.
Question 4 of 9
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to focus the interview on the patient's needs. This step helps in gathering important information and establishing rapport. Introductions are usually done at the beginning of the interview, so it is not the next step. Explaining that the interview will be over in a few minutes can create anxiety and hinder open communication. Telling the patient about administering medications in 1 hour is not relevant at this point in the interview.
Question 5 of 9
JR is admitted to the medical-surgical unit because of a diagnosis of nephritic syndrome. What is the hallmark of this syndrome?
Correct Answer: C
Rationale: The hallmark of nephritic syndrome is edema due to proteinuria leading to hypoalbuminemia. Protein loss in urine causes decreased colloid osmotic pressure, leading to fluid leaking into tissues, causing edema. Osmotic diuresis (A) is unrelated to nephritic syndrome. Hypolipidemia (B) and hyperproteinemia (D) are not characteristic of nephritic syndrome.
Question 6 of 9
Three days after admission Ms. CC continued to have frequent stools. Her oral intake of both fluids and solids are poor. Her physician ordered parenteral hyperalimentation. Hyperalimentation solutions are:
Correct Answer: D
Rationale: The correct answer is D: Hyperosmolar solutions used primarily to reverse negative nitrogen balance. Rationale: 1. Hyperalimentation solutions are designed to provide essential nutrients intravenously. 2. Hyperosmolar solutions have a higher osmolarity compared to body fluids, providing concentrated nutrition. 3. Negative nitrogen balance occurs when the body breaks down more protein than it synthesizes, requiring additional protein intake. 4. Hyperosmolar solutions can provide adequate protein and nutrients to reverse negative nitrogen balance. Summary: A: Hypotonic solutions do not increase osmotic pressure, but rather decrease it. B: Hypertonic solutions are not primarily used for hydration in this context. C: Alkalizing solutions are not the primary purpose of hyperalimentation and do not directly address cellular sweating.
Question 7 of 9
During a breast examination, which finding most strongly suggests that the client has breast cancer?
Correct Answer: B
Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is a classic sign of breast cancer. This finding is concerning as it indicates an abnormal growth that has invaded surrounding tissues. Dimpling occurs due to fibrotic changes pulling on the skin. Choices A, C, and D are incorrect. A slight asymmetry of the breasts is common and not necessarily indicative of cancer. Bloody discharge from the nipple can be a sign of other conditions like intraductal papilloma. Multiple firm, round, freely movable masses that change with the menstrual cycle are likely benign fibrocystic changes.
Question 8 of 9
A female client age 66 is admitted ff a nephrolithomy. One of her laboratory tests reveals a urinary tract infection. Which would be the best nursing action in her case?
Correct Answer: C
Rationale: Correct Answer: C - Encourage fluid intake of 3000ml/day Rationale: Encouraging fluid intake of 3000ml/day helps to flush out bacteria from the urinary tract, reducing the risk of infection spread. Adequate hydration also prevents further stone formation. Incorrect Choices: A: Administering IV fluids and blood transfusions may not directly address the urinary tract infection. B: Administering narcotic analgesics may mask symptoms but not treat the root cause of the infection. D: Suggesting herbs or spices does not address the need for adequate fluid intake to manage the urinary tract infection.
Question 9 of 9
A patient visiting with family members in the waiting area tells the nurse “I don’t feel good, especially in the stomach.” What should the nurse do?
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to return to the room, so the nurse can inspect the abdomen. Rationale: 1. Patient safety: By examining the patient's abdomen, the nurse can assess for any signs of distress or potential medical issues. 2. Patient-centered care: It is essential to prioritize the patient's well-being by addressing their concerns promptly and appropriately. 3. Professional responsibility: Nurses are trained to assess and evaluate patient symptoms to provide necessary care and support. Summary: A: Requesting the family to leave does not address the patient's symptoms and may disrupt the patient's support system. C: Asking about bowel movements and offering food may not be appropriate if the patient is experiencing stomach discomfort. D: Offering food without proper assessment may worsen the patient's condition and is not recommended before a proper evaluation.