ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
While managing a client after a medical or surgical procedure for bladder stones, for what rise in the temperature should the nurse notify the physician?
Correct Answer: C
Rationale: The correct answer is C: When the temperature rises above 102F. A temperature rise above 102F is concerning as it may indicate infection or other complications post-procedure. This higher threshold helps in early detection and timely intervention. Choices A and B set lower thresholds, potentially delaying necessary medical attention. Choice D is below the typical threshold for fever and would not typically warrant physician notification in this context.
Question 2 of 5
The following. items are transported in blood plasma, EXCEPT:
Correct Answer: A
Rationale: The correct answer is A: Oxygen. Oxygen is primarily transported in the blood bound to hemoglobin within red blood cells, not dissolved in plasma. Carbon dioxide is transported in plasma. Nutrients and hormones are also transported in plasma. Therefore, choice A is incorrect as oxygen is not primarily transported in plasma.
Question 3 of 5
Which of the ff is an assessment finding in a client with bonchiectasis?
Correct Answer: D
Rationale: The correct answer is D. In bronchiectasis, worsening cough with position changes is an assessment finding due to increased sputum production and airway obstruction. This occurs because of the pooling of secretions in the affected bronchi. Choices A, B, and C are incorrect because in bronchiectasis, there is typically increased sputum production over time, productive cough with expectoration of large amounts of sputum, and cough that worsens with activity or physical exertion, rather than with position changes.
Question 4 of 5
A Jewish client has been diagnosed with ulcerative colitis. A nursing diagnosis appropriate for a client who has ulcerative colitis is:
Correct Answer: A
Rationale: The correct answer is A: abdominal pain related to decreased peristalsis. Ulcerative colitis causes inflammation and ulcers in the colon, leading to abdominal pain due to decreased peristalsis. This impairs the movement of stool through the colon, resulting in pain. Choice B is incorrect as diarrhea is a common symptom of ulcerative colitis, not hyperosmolar intestinal contents. Choice C is incorrect as ulcerative colitis often leads to diarrhea and not fluid volume excess. Choice D is incorrect as activity intolerance is not directly related to ulcerative colitis, whereas abdominal pain is a common symptom associated with the condition.
Question 5 of 5
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
Correct Answer: B
Rationale: The correct answer is B because decorticate posturing is characterized by the flexion of elbows, wrists, and fingers, extension of elbows and knees, plantar flexion of feet. This pattern indicates damage to the cerebral hemispheres or internal structures of the brain. In contrast, option A describes decerebrate posturing, which indicates more severe brain damage. Option C is incorrect as it describes a mixed pattern of posturing. Option D is also incorrect as it describes a different type of posturing called decerebrate posturing.
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