ATI RN
Nursing Process Questions Questions
Question 1 of 9
Which points should a nurse includes in the discharge teaching plan for a client after cardiac surgery?
Correct Answer: B
Rationale: The correct answer is B because it addresses the importance of notifying the physician about a painless lump at the top of the chest incision, which could indicate a serious complication like a seroma or hematoma. This is crucial for early detection and intervention. A is incorrect because showers are generally allowed after cardiac surgery as long as the incisions are kept clean and dry. C is incorrect because support hose or elastic stockings are typically recommended to be worn during the day and removed at night to prevent swelling and promote circulation. D is incorrect because resuming sexual relations after cardiac surgery should be based on individual recovery and should be discussed with the healthcare provider, rather than a standard timeframe.
Question 2 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 3 of 9
When a neurologist asks a patient to smile, which cranial nerve is being tested?
Correct Answer: C
Rationale: Step-by-step rationale: 1. The cranial nerve responsible for facial expression is CN VII, the facial nerve. 2. When a neurologist asks a patient to smile, they are testing the function of CN VII. 3. CN II (optic nerve) is responsible for vision, not facial expression. 4. CN X (vagus nerve) is responsible for various functions like heart rate and digestion, not facial expression. 5. CN XI (accessory nerve) is responsible for shoulder movement, not facial expression. Summary: Testing a patient's ability to smile involves assessing the function of CN VII, the facial nerve. Choices A, B, and D are incorrect as they are associated with different functions and not responsible for controlling facial muscles.
Question 4 of 9
A patient’s serum sodium is within normal range. The nurse estimates that serum osmolality should be:
Correct Answer: C
Rationale: The correct answer is C (280 to 295mOsm/kg) because serum osmolality is primarily determined by sodium, glucose, and blood urea nitrogen levels. Normal serum sodium range is 135-145 mEq/L, which corresponds to an osmolality range of 280-295 mOsm/kg. Choices A and B are incorrect as they do not align with normal serum sodium levels. Choice D is incorrect as it includes an excessively wide range that is not consistent with normal osmolality values.
Question 5 of 9
A client diagnosed with DIC is ordered heparin. What is the reason for this medication?
Correct Answer: A
Rationale: The correct answer is A: Prevent clot formation. Heparin is an anticoagulant that inhibits the formation of blood clots. In DIC (Disseminated Intravascular Coagulation), there is excessive clotting throughout the body, leading to organ damage. By administering heparin, we aim to prevent further clot formation and reduce the risk of complications. Choice B is incorrect because heparin does not increase clot formation; it works to inhibit clotting. Choice C is incorrect as heparin does not directly increase blood flow to target organs. Choice D is also incorrect as heparin does not decrease blood flow to target organs; its primary role is anticoagulation.
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 nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. The nurse chose this diagnosis based on the patient's chest x-ray results indicating lower lobe infiltrates, which directly affect gas exchange. Choice A is incorrect because "ineffective breathing pattern" does not specifically address the underlying physiological issue of impaired gas exchange. Choice B is incorrect as it focuses on infection risk from the chest x-ray procedure, not the patient's medical condition. Choice C is incorrect as dehydration is not directly related to pneumonia and infiltrates.
Question 7 of 9
An adult is being taught about a healthy diet. How can the food pyramid help guide the client on his diet?
Correct Answer: C
Rationale: The correct answer is C because the food pyramid suggests daily food choices based on the different food groups. It provides a visual guide on the proportions of each food group to consume for a balanced diet. It does not specify the exact number of servings (A), calculate calories (B), or divide food into four basic groups (D). The food pyramid is a tool to help individuals make healthier food choices by emphasizing variety and moderation.
Question 8 of 9
. Which of the following laboratory test results would suggest to the nurse that a client has a corticotrophin- secreting pituitary adenoma?
Correct Answer: B
Rationale: Step-by-step rationale: 1. Corticotropin-secreting pituitary adenoma leads to excess adrenocorticotropic hormone (ACTH) production. 2. High corticotropin levels would be expected due to the adenoma's overproduction. 3. The high cortisol levels occur as a result of increased ACTH stimulating cortisol release from the adrenal glands. 4. Therefore, choice B (high corticotropin and high cortisol levels) is the correct answer. Summary: - Choice A is incorrect because low cortisol levels would not be expected in a client with a corticotrophin-secreting pituitary adenoma. - Choice C is incorrect because low corticotropin levels would not align with the excessive ACTH production from the adenoma. - Choice D is incorrect as both low corticotropin and low cortisol levels would not be consistent with the pathophysiology of a corticotrophin-secreting pituitary adenoma.
Question 9 of 9
A client has undergone the Snellen eye chart test and has 20/40 vision. Which of the ff is true for this client?
Correct Answer: A
Rationale: The correct answer is A. In the Snellen eye chart test, the first number (20) represents the distance at which the client is viewing the chart, and the second number (40) represents the distance at which a person with normal vision can read the same line. Therefore, a client with 20/40 vision sees letters at 20 feet that others with normal vision can read at 40 feet. Choices B, C, and D are incorrect because they do not accurately reflect the interpretation of the 20/40 vision result from the Snellen eye chart test. B is incorrect because the client does not see letters at 40 feet that others can read at 20 feet. Choices C and D are incorrect because the Snellen eye chart test measures visual acuity, not color perception.