Questions 9

ATI RN

ATI RN Test Bank

ADPIE Nursing Process Questions Questions

Question 1 of 5

Which patient is most at risk for fluid volume overload?

Correct Answer: C

Rationale: The correct answer is C, the 35-year-old with kidney failure. Patients with kidney failure are at high risk for fluid volume overload due to the kidneys' inability to properly regulate fluid balance. This can lead to accumulation of excess fluids in the body, causing edema, hypertension, and heart failure. In contrast, choices A, B, and D are not at as high risk for fluid volume overload as patients with kidney failure, as their conditions do not directly impact fluid regulation in the body.

Question 2 of 5

Which of the following types of cells is the immune system’s shutoff mechanism?

Correct Answer: B

Rationale: The correct answer is B: Suppressor T cells. Suppressor T cells regulate the immune response by inhibiting the activity of other immune cells to prevent overreaction and maintain immune balance. They play a crucial role in preventing autoimmune diseases and excessive inflammation. Plasma cells (A) produce antibodies, Helper T cells (C) assist in activating other immune cells, and B lymphocytes (D) are involved in antibody production. Suppressor T cells specifically have the function of shutting down immune responses, making them the immune system’s shutoff mechanism.

Question 3 of 5

The following are warning signs of cancer. Which one is not?

Correct Answer: B

Rationale: The correct answer is B, weight gain, as it is not typically considered a warning sign of cancer. Changes in bladder and bowel habits (A), indigestion or difficulty in swallowing (C), and a nagging cough or hoarseness (D) are commonly associated with various types of cancer. Weight gain is more commonly linked to factors such as diet, exercise, and hormonal imbalances rather than cancer. It is important to be vigilant about the other warning signs and seek medical attention if any of those symptoms persist.

Question 4 of 5

Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?

Correct Answer: B

Rationale: The correct answer is B: Acute pain. NANDA-I (North American Nursing Diagnosis Association International) approves standardized nursing diagnoses to guide nursing care. Acute pain is a NANDA-I approved diagnosis as it helps identify and address a patient's pain experience. It is specific, measurable, and relevant for care planning. Sore throat (A) is a symptom, not a diagnosis. Sleep apnea (C) and heart failure (D) are medical conditions, not nursing diagnoses. The focus of nursing care plans is on identifying patient responses to health conditions, which is why acute pain is the most appropriate choice.

Question 5 of 5

After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported

Correct Answer: C

Rationale: Rationale: 1. Safety: Recording vital signs is crucial for patient safety. 2. Accountability: The nurse is ultimately responsible for ensuring vital signs are documented accurately. 3. Communication: It is essential for the nurse to communicate with the NAP to address the missed vital signs. 4. Corrective Action: Asking the NAP to record vital signs before administering medications ensures proper monitoring. 5. Patient-Centered Care: Prioritizing patient well-being by ensuring vital signs are up-to-date. Summary: A: Incorrect. Administering medications without vital sign assessment is unsafe. B: Incorrect. Reviewing vital signs upon return does not address the immediate need for accurate documentation. D: Incorrect. Omitting vital signs compromises patient safety and violates standard nursing practice.

Similar Questions

Join Our Community Today!

Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for ATI-RN and 3000+ practice questions to help you pass your ATI-RN exam.

Call to Action Image