ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
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 5
The nurse knows that a client understands a low residue diet when he selects which of the following from the menu?
Correct Answer: A
Rationale: The correct answer is A: Rice and lean chicken. A low residue diet aims to reduce fiber intake to ease digestion. Rice and lean chicken are low in fiber and easy to digest. Pasta with vegetables (B) contains high-fiber vegetables. Strawberry pie (C) is high in fiber due to fruit and crust. Tuna casserole (D) may contain high-fiber ingredients like noodles and vegetables. Therefore, A is the best choice for a low residue diet.
Question 3 of 5
An adult has a central venous line. Which of the following should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D because monitoring for signs of infection, air embolus, and leakage/puncture are crucial in caring for a patient with a central venous line to prevent serious complications. Infections can lead to sepsis, air embolus can cause respiratory distress, and leakage/puncture can result in hemorrhage or damage to surrounding tissues. A: While a complete blood count and electrolytes may be important for monitoring the patient's overall health, they are not specific to the central venous line care. B: Regular chest x-rays are not necessary unless there are specific indications of line malposition or complications. C: Continuous infusion at a keep-vein-open rate is a standard practice but does not address the critical aspects of central line care mentioned in option D. Therefore, monitoring for signs of infection, air embolus, and leakage/puncture is the most essential component of the plan of care for a patient with a central venous line.
Question 4 of 5
Bell’s palsy is a ___ cranial nerve disorder characterized by weakness or paralysis of the facial muscles.
Correct Answer: B
Rationale: The correct answer is B: 7th cranial nerve. Bell's palsy is caused by inflammation of the facial nerve (7th cranial nerve), leading to facial muscle weakness or paralysis. The 3rd cranial nerve (choice A) controls eye movement, the 5th cranial nerve (choice C) is responsible for facial sensation and chewing, and the 8th cranial nerve (choice D) is related to hearing and balance. Bell's palsy specifically affects the facial muscles, making choice B the correct answer.
Question 5 of 5
Appropriate nursing interventions for J.E. would be
Correct Answer: A
Rationale: The correct answer is A because it includes essential nursing interventions for a patient with head injuries like J.E. Skin care and position changes every 2 hours help prevent pressure ulcers. Maintaining alignment of extremities prevents contractures. Respiratory exercises aid in lung function. Option B lacks the crucial aspect of maintaining extremity alignment. Option C includes teaching the use of an overhead trapeze, which may not be appropriate for J.E. Option D lacks the instruction to maintain extremity alignment, which is crucial for preventing contractures in patients with head injuries.