ATI RN
Nursing Process Exam Questions Questions
Question 1 of 9
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
Correct Answer: A
Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.
Question 2 of 9
Which of the ff. would the nurse explain to the patient is indicated by a Snellen chart finding 20/80?
Correct Answer: B
Rationale: The correct answer is B because a Snellen chart reading of 20/80 means the patient can see at 20 feet what a normal eye can see at 80 feet. This indicates that the patient's vision is below average. Choice A is incorrect because it reverses the numerator and denominator. Choice C is incorrect because it does not accurately represent the Snellen chart findings. Choice D is incorrect because 20/80 is not considered normal vision.
Question 3 of 9
The nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client’s blood and body fluids, the nurse uses standard precautions, which include:
Correct Answer: A
Rationale: The correct answer is A. Standard precautions include wearing gloves when there is a potential for contact with blood or body fluids. Emptying a bedpan involves contact with bodily fluids, thus gloves are necessary to prevent exposure to pathogens. Choice B is incorrect because wearing a gown and protective eyewear is not necessary for obtaining a urine specimen via catheterization unless there is a risk of splashing or spraying of fluids. Choice C is incorrect as needles should always be disposed of in a proper sharps container with the cap secured to prevent accidental needlestick injuries. Choice D is incorrect because applying eyedrops does not involve contact with blood or body fluids, so wearing gloves is not necessary according to standard precautions.
Question 4 of 9
A nurse changes a client’s wound dressing according to the protocol outlined by the health care agency. What type of nursing intervention is this?
Correct Answer: C
Rationale: The correct answer is C: Interdependent intervention. This type of nursing intervention involves collaboration with other healthcare professionals to provide holistic care. In this scenario, the nurse is following a protocol set by the health care agency, which likely involves input and guidance from various team members. The nurse's actions require coordination and communication with others to ensure the best outcome for the client. Choice A (Independent intervention) would involve actions that the nurse can perform autonomously without requiring direction from others. Choice B (Dependent intervention) would require an order or prescription from a healthcare provider for the nurse to carry out. Choice D (Collaborative intervention) involves working together with other healthcare professionals on a specific aspect of care, but in this case, the nurse is primarily following a set protocol without necessarily actively collaborating with others during the task.
Question 5 of 9
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking the beta receptors in the heart, which reduces the heart's workload and oxygen demand, making it an effective treatment for angina. By blocking beta stimulation, propranolol helps to decrease heart rate, blood pressure, and myocardial contractility. This ultimately improves oxygen supply to the heart muscle. Explanation for other choices: A: Act as a vasoconstrictor - Propranolol does not act as a vasoconstrictor; it actually can cause vasodilation in some cases. C: Act as a vasodilator - Propranolol is not primarily a vasodilator; its main action is to block beta stimulation in the heart. D: Increase the heart rate - Propranolol actually decreases heart rate by blocking beta receptors in the heart.
Question 6 of 9
The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?
Correct Answer: A
Rationale: The correct answer is A because gathering and organizing needed supplies is a crucial step before performing a complex dressing change. By ensuring all necessary supplies are readily available, the nurse can streamline the process, minimize interruptions, and promote efficiency. This step also helps maintain aseptic technique and prevent the spread of infection. Deciding on goals and outcomes (B) is important but typically done as part of the care planning process, not immediately before a dressing change. Assessing the patient's readiness (C) is also important but can be done concurrently with gathering supplies. Calling for assistance (D) may be necessary in some situations, but it is not the immediate step required just before changing the dressing.
Question 7 of 9
Which of the ff precautions must a nurse take while caring for clients with HIV/AIDS to reduce occupational risks?
Correct Answer: A
Rationale: The correct answer is A. Transporting specimens of body fluid in leakproof containers reduces the risk of exposure to HIV/AIDS. This precaution ensures that any potentially infectious material is securely contained. Choice B is incorrect as fusion inhibitors are not prescribed for reducing occupational risks. Choice C is incorrect as it does not directly address reducing occupational risks related to HIV/AIDS. Choice D is incorrect as it is essential for a nurse to clean the client's room, but with proper precautions in place to prevent exposure to bodily fluids.
Question 8 of 9
Which of the following is not a criterion for a valid informed consent that a nurse should identify?
Correct Answer: B
Rationale: The correct answer is B: with coercion. Informed consent must be freely given without any form of coercion to ensure the individual's autonomy and decision-making capacity. Coercion can lead to involuntary consent, undermining the principle of respect for autonomy. Choices A, C, and D are all criteria for valid informed consent. Choice A ensures the individual is voluntarily agreeing without any external pressure. Choice C ensures the individual understands the procedures involved, promoting transparency. Choice D ensures the individual is aware of alternative options, allowing for an informed decision-making process.
Question 9 of 9
The initial neurological symptom of Guilain-Barre Syndrome is:
Correct Answer: B
Rationale: Step 1: Guillain-Barre Syndrome (GBS) is characterized by a rapid onset of weakness and tingling sensations in the legs. Step 2: Paresthesia refers to abnormal sensations like tingling or numbness, which is a common initial neurological symptom of GBS. Step 3: Absent tendon reflexes may occur in GBS due to muscle weakness but are not typically the initial symptom. Step 4: Dysrhythmias and transient hypertension are not typical symptoms of GBS and are not associated with its initial presentation. In summary, choice B is correct as paresthesia of the legs is a hallmark initial neurological symptom of Guillain-Barre Syndrome, while choices A, C, and D are incorrect as they do not align with the typical presentation of GBS.