ATI RN
Nursing Process Questions Questions
Question 1 of 9
Which patient should be monitored most closely for dehydration?
Correct Answer: A
Rationale: The correct answer is A, the 50-year-old with an ileostomy, should be monitored most closely for dehydration. Patients with an ileostomy have a higher risk of dehydration due to increased fluid loss through the stoma. Monitoring their fluid intake, output, electrolyte levels, and signs of dehydration is crucial to prevent complications. The other choices are less likely to experience severe dehydration compared to the patient with an ileostomy. The 72-year-old with diabetes mellitus may be at risk for dehydration, but it is not as high a risk as the patient with an ileostomy. The 19-year-old with chronic asthma and the 28-year-old with a broken femur are not as directly related to dehydration compared to the patient with an ileostomy.
Question 2 of 9
Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?
Correct Answer: B
Rationale: The correct answer is B because monitoring for swelling and heaviness of legs is essential in preventing falls, which can be caused by conditions like edema or circulatory issues. Swollen or heavy legs can affect mobility and balance, increasing the risk of falls. This intervention helps identify potential issues early and implement preventive measures. Choice A is incorrect as monitoring for chest pain and LDL levels pertains more to cardiovascular health than fall prevention. Choice C is incorrect because monitoring postural changes in BP is important for managing hypertension, not necessarily for preventing falls. Choice D is incorrect as monitoring temperature for mild fever is more related to identifying infections rather than preventing falls.
Question 3 of 9
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, leading to impaired gas exchange. The nurse correctly identified the underlying respiratory issue. A: Ineffective breathing pattern related to pneumonia is incorrect as it focuses on the pattern of breathing rather than the physiological problem causing the breathing difficulty. B: Risk for infection related to chest x-ray procedure is incorrect as the patient already has a diagnosis of pneumonia, so the focus should be on managing the existing condition. C: Risk for deficient fluid volume related to dehydration is incorrect as there is no indication of dehydration in the question stem. In summary, the nurse's diagnosis of Impaired gas exchange related to alveolar-capillary membrane changes is the most appropriate as it addresses the respiratory issue caused by pneumonia and lower lobe infiltrates.
Question 4 of 9
The couple with the lowest risk of having a child with sickle cell disease is the one in which the:
Correct Answer: D
Rationale: The correct answer is D because sickle cell disease is an autosomal recessive genetic disorder. The disease is caused by inheriting two copies of the abnormal hemoglobin gene (HbS). In choice D, the father is HbA (normal) and the mother is HbS (carrier). This combination ensures that the child will inherit one normal gene and one abnormal gene, making them a carrier like the mother but not affected by the disease. Choices A, B, and C all involve at least one parent who carries the HbS gene, increasing the risk of the child having sickle cell disease.
Question 5 of 9
The spouse of a client with gastric cancer expresses concern that the couple’s children may develop this type of cancer when they’re older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
Correct Answer: A
Rationale: Step 1: Type A blood has been associated with a slightly higher risk of developing gastric cancer compared to other blood types. Step 2: The nurse mentioned a 10% increase in risk, which aligns with the increased risk associated with Type A blood. Step 3: Type AB and Type B blood do not have the same increased risk for gastric cancer as Type A blood. Step 4: Type O blood is actually associated with a lower risk of gastric cancer compared to Type A blood. Step 5: Therefore, the correct answer is A: Type A blood.
Question 6 of 9
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This is the most appropriate nursing diagnosis for a patient with pneumonia and lower lobe infiltrates. The rationale is that pneumonia causes inflammation and fluid accumulation in the alveoli, impairing the exchange of oxygen and carbon dioxide in the lungs. This directly affects gas exchange. Choice A is incorrect because ineffective breathing pattern is a broad nursing diagnosis that does not specifically address the underlying issue of impaired gas exchange in pneumonia. Choice B is incorrect as the risk of infection related to the chest x-ray procedure is unrelated to the patient's current condition of pneumonia. Choice C is also incorrect as dehydration does not directly correlate with the patient's diagnosis of pneumonia and lower lobe infiltrates.
Question 7 of 9
Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards?
Correct Answer: B
Rationale: Correct Answer: B (State Nurse Practice Acts) Rationale: State Nurse Practice Acts outline the legal scope of nursing practice, including standards for setting priorities, identifying client outcomes, and selecting evidence-based nursing interventions. These laws are specific to nursing practice, ensuring that nurses follow guidelines tailored to their profession. Nurses must adhere to these standards to provide safe and effective care. Summary of Incorrect Choices: A: Professional physicians' organizations - While physicians' organizations may provide guidelines for medical practice, they do not set standards specific to nursing practice. C: The Joint Commission - The Joint Commission focuses on accreditation for healthcare organizations, not setting standards for nursing practice. D: The Agency for Health Care Research and Quality - AHRQ conducts research and provides evidence-based information but does not establish standards for nursing practice.
Question 8 of 9
A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data?
Correct Answer: B
Rationale: Subjective data refers to information provided by the client based on their feelings, perceptions, or beliefs. Nausea is a symptom that the client experiences and reports subjectively. The client feels nauseous, which is not something directly measurable like blood pressure, heart rate, or respiratory rate. Therefore, nausea is the correct choice for subjective data. Blood pressure, heart rate, and respiratory rate are all objective data that can be measured and observed. Blood pressure, heart rate, and respiratory rate are all objective data that can be measured and observed.
Question 9 of 9
Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Dressing changes twice a day help maintain a clean wound environment, reducing the risk of infection. 2. Regular dressing changes promote proper wound healing by facilitating moisture balance and removal of dead tissue. 3. It is a direct intervention that addresses the patient's poor wound healing. 4. Teaching the patient about signs of infection (B) is important but does not directly address the wound healing process. 5. Instructing the family on dressing changes (C) is helpful but should not substitute direct patient care. 6. Refocusing the patient from body image changes (D) is not directly related to improving wound healing.