ATI RN
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 ff symptoms should a nurse assess in a client when implementing interventions for trauma to the upper airway?
Correct Answer: D
Rationale: The correct answer is D: Presence of laryngospasm. Laryngospasm is a serious complication of trauma to the upper airway that can lead to airway obstruction. Assessing for laryngospasm is crucial to ensure the client's airway remains patent. Pain when talking (A) is more related to vocal cord injury, increased nasal swelling (B) is a symptom of nasal trauma, and burning in the throat (C) may indicate pharyngeal injury, but laryngospasm (D) directly affects airway patency in upper airway trauma cases.
Question 3 of 5
Which of the ff nursing interventions is involved when caring for a client with influenza?
Correct Answer: C
Rationale: The correct answer is C: Immediate recognition of respiratory distress. This is crucial when caring for a client with influenza as the virus can lead to respiratory complications. Prompt recognition allows for timely intervention and prevents further deterioration. A: Maintaining airborne transmission is incorrect as the goal is to prevent the spread of influenza through droplet precautions, not airborne transmission. B: Oxygen administration may be necessary for severe cases of influenza, but immediate recognition of respiratory distress takes precedence in the nursing interventions. D: Complete bed rest is not recommended for influenza as mobilization and deep breathing exercises are important to prevent complications like pneumonia.
Question 4 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 5 of 5
A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?
Correct Answer: D
Rationale: The correct answer is D: The client's ability to produce antibodies. This is crucial in assessing immune system disorders as antibodies play a key role in fighting infections and other foreign invaders. By evaluating the client's ability to produce antibodies, the nurse can determine if the immune system is functioning properly. A: The client's diet is not directly related to immune system disorders unless there are specific deficiencies impacting immune function. B: The client's family member's history of chronic diseases may provide some genetic predisposition information but does not directly assess the client's immune system. C: The client's drug history is important but more relevant to medication interactions and side effects rather than evaluating the immune system.