ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 9
Why should the nurse monitor angiotensin converting enzyme inhibitors cautiously in clients with renal or hepatic impairment and in older adults?
Correct Answer: B
Rationale: The correct answer is B: A sudden drop in BP may occur during the first 1-3 hours after the initial dose. Angiotensin converting enzyme inhibitors can cause vasodilation, leading to a reduction in blood pressure. In clients with renal or hepatic impairment and in older adults, these medications may not be cleared from the body as efficiently, increasing the risk of hypotension. Monitoring is crucial to prevent complications. Incorrect choices: A: A sudden raise in BP is unlikely with angiotensin converting enzyme inhibitors. C: Angiotensin converting enzyme inhibitors do not affect body temperature. D: Angiotensin converting enzyme inhibitors typically do not cause a sudden rise in pulse rate. In summary, monitoring for a potential drop in blood pressure is essential in vulnerable populations when using angiotensin converting enzyme inhibitors.
Question 2 of 9
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.
Question 3 of 9
The nurse is teaching a client with type 1 diabetes mellitus how to treat adverse reactions to insulin. To reverse a hypoglycemic reaction, the client ideally should ingest an oral carbohydrate. However, this treatment isn’t always a possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?
Correct Answer: C
Rationale: The correct answer is C: Glucagon. In a hypoglycemic reaction, glucagon can be administered to raise blood sugar levels quickly. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. This is crucial in emergencies when oral carbohydrates are not feasible. Epinephrine (A) is used for severe allergic reactions, not hypoglycemia. 50% dextrose (B) is an oral carbohydrate used for hypoglycemia but is not always practical. Hydrocortisone (D) is a corticosteroid used for inflammatory conditions, not for hypoglycemic emergencies.
Question 4 of 9
Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:
Correct Answer: B
Rationale: The correct answer is B because encouraging the intake of low-sodium liquids like coffee or tea can worsen hyponatremia. Hyponatremia is a condition characterized by low sodium levels in the blood, so encouraging low-sodium liquids would further dilute the sodium levels. The other choices are correct interventions for hyponatremia: A) assessing for symptoms helps in monitoring the patient's condition, C) monitoring neurological status is crucial as hyponatremia can lead to neurological complications, and D) restricting tap water intake helps in managing fluid intake and preventing further dilution of sodium levels.
Question 5 of 9
A client with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
Correct Answer: A
Rationale: The correct answer is A: Vision changes. This is crucial to report immediately because tamoxifen can cause serious eye problems such as retinopathy. Vision changes could indicate a potentially serious adverse reaction that requires prompt medical attention to prevent permanent damage. Headache, hearing loss, and anorexia are not typically associated with tamoxifen use and are less urgent in nature. Reporting vision changes promptly can help prevent irreversible harm and ensure timely intervention.
Question 6 of 9
A patient has hand-foot syndrome related to his sickle cell anemia. What findings does the nurse expect to see as the patient is assessed?
Correct Answer: B
Rationale: The correct answer is B: Purplish discoloration of hands and feet. Hand-foot syndrome in sickle cell anemia is characterized by pain, swelling, and purplish discoloration of the hands and feet due to vaso-occlusive crisis. Unequal growth of fingers and toes (A), webbing between fingers and toes (C), and deformities of wrists and ankles (D) are not typical findings associated with hand-foot syndrome in sickle cell anemia.
Question 7 of 9
. During the first 24 hours after a client is diagnosed with Addisonian crisis, which of the following should the nurse perform frequently?
Correct Answer: D
Rationale: The correct answer is D, assess vital signs, as it is crucial to monitor the client's hemodynamic stability and response to treatment during the critical initial 24 hours of Addisonian crisis. Vital signs such as blood pressure, heart rate, and respiratory rate provide valuable information about the client's condition and response to therapy. Weighing the client (choice A) and testing urine for ketones (choice C) may be important but not as immediately critical as monitoring vital signs. Administering oral hydrocortisone (choice B) is essential for treatment but does not require frequent administration within the first 24 hours.
Question 8 of 9
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 the patient with a right femur fracture stabilized in a full leg cast is "Acute pain" (Choice C). The rationale for this is as follows: 1. The patient is experiencing moderate discomfort due to the fracture and immobilization in the cast, indicating a need for pain management. 2. Acute pain is a priority in this situation as it can impact the patient's comfort, mobility, and overall recovery. 3. Managing pain effectively is crucial for promoting healing, preventing complications, and improving the patient's quality of life. 4. Posttrauma syndrome (Choice A) may be a consideration in the long term but is not the immediate priority. Constipation (Choice B) is not the most pertinent nursing diagnosis in this scenario. Anxiety (Choice D) may be present but addressing pain is more urgent and directly related to the patient's current condition.
Question 9 of 9
Which is the most reliable method for monitoring fluid balance?
Correct Answer: A
Rationale: The correct answer is A: Daily intake and output. Monitoring fluid balance involves tracking the amount of fluids taken in and expelled from the body. Intake includes oral, IV, and tube feedings, while output includes urine, vomitus, diarrhea, and any other fluid losses. Daily intake and output provide a comprehensive view of a patient's fluid status, helping identify trends and potential issues. Vital signs (B) provide general information but not specific to fluid balance. Daily weight (C) can fluctuate due to various factors, not just fluid status. Skin turgor (D) is a late sign of dehydration and not as reliable as intake and output monitoring.