ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
Why should clients who take warfarin (Coumadin) refrain from food items such as green leafy vegetables and soybeans?
Correct Answer: A
Rationale: The correct answer is A because green leafy vegetables and soybeans are high in Vitamin K, which counteracts the anticoagulant effect of warfarin. Warfarin works by inhibiting Vitamin K-dependent clotting factors in the liver. By consuming Vitamin K-rich foods, the medication's effectiveness is reduced, leading to an increased risk of blood clot formation. Choices B, C, and D are incorrect because they do not address the specific interaction between Vitamin K and warfarin in affecting coagulation. Choice B suggests the opposite effect of what actually occurs. Choices C and D are irrelevant to the pharmacological mechanism of warfarin.
Question 2 of 5
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Acute pain. The patient's right femur fracture would likely cause significant pain. Treating the pain is a priority to ensure the patient's comfort and promote healing. Posttrauma syndrome (A) is more applicable for patients experiencing emotional distress following a traumatic event. Constipation (B) may be a concern due to immobility but is not as immediate as managing pain. Anxiety (D) may be present but addressing the acute pain would likely alleviate some anxiety as well.
Question 3 of 5
24 hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:
Correct Answer: A
Rationale: The correct answer is A: Removal of the transplanted kidney. Hyperacute rejection is a severe and immediate immune response to the transplanted organ. In this case, the transplanted kidney must be removed promptly to prevent further complications, as it is irreversibly damaged. High-dose IV cyclosporine (B) is used for immunosuppression but is not effective in treating hyperacute rejection. Bone marrow transplant (C) is not indicated for kidney rejection. Intra-abdominal instillation of methylprednisolone sodium succinate (D) is used for acute rejection, not hyperacute rejection.
Question 4 of 5
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
Correct Answer: C
Rationale: The correct answer is C. Rolling Mr. Gabatan on his abdomen, placing a pad under his head, and covering him with any material available is the appropriate action. This position helps protect his airway and prevents potential complications from a possible spinal injury. It also allows for better assessment of his condition by healthcare professionals. Choice A is incorrect because leaving Mr. Gabatan on his back and instructing him to move can worsen any spinal injury he may have sustained. Choice B is incorrect because raising him to a sitting position can also exacerbate his condition. Choice D is incorrect because moving him without proper stabilization can lead to further injury.
Question 5 of 5
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for this patient is acute pain (Choice C). This is because the patient's right femur fracture would likely cause significant pain and discomfort, which is a priority to address for optimal recovery and comfort. Managing pain effectively is crucial in promoting healing and preventing complications. Posttrauma syndrome (Choice A) is not as immediate a concern in this scenario. While constipation (Choice B) and anxiety (Choice D) are important considerations, addressing acute pain takes precedence in the initial plan of care to ensure the patient's comfort and well-being.
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