ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self- examination. Which assessment finding would strongly suggest that this client�s lump is cancerous?
Correct Answer: C
Rationale: The correct answer is C: Non-mobile mass with irregular edges delineated. This finding strongly suggests cancer as non-mobile masses with irregular edges are characteristic of malignant tumors. Cancerous lumps tend to be fixed in place due to involvement of surrounding tissues. Irregular edges indicate potential invasive growth. Choices A and B describe characteristics more commonly associated with benign masses. Eversion of the nipple is concerning for cancer but not specific enough to strongly suggest malignancy. Choice D indicates absence of lymph node involvement, which is not directly related to the characteristics of the breast lump.
Question 2 of 5
A client with diabetes mellitus has a prescription for 5 U-100 regular insulin and 25 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?
Correct Answer: C
Rationale: The correct answer is C: Hypoglycemia. At 4:30 p.m., after taking the morning insulin, the client's blood sugar may have dropped too low, leading to symptoms like headache, sweating, tremor, pallor, and nervousness. Regular insulin and NPH insulin peak at different times, causing a potential mismatch in insulin action, leading to hypoglycemia. Hyperglycemia (A) would present with different symptoms like increased thirst and urination. Hyperuricemia (B) is an excess of uric acid in the blood and does not typically present with these symptoms. Hypochondria (D) is a psychological condition and not related to the client's physical symptoms.
Question 3 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 4 of 5
What is the last step when inserting an IV cannula?
Correct Answer: A
Rationale: The correct answer is A: Secure the cannula with tape. This is the last step in inserting an IV cannula to ensure it stays in place and prevents dislodgement or movement. Securing the cannula with tape helps maintain proper positioning and prevents accidental removal. Documenting the insertion site, date, and type of cannula used (B) is important but typically done earlier in the process. Assessing the site (C) should be done before securing the cannula to ensure proper placement. Placing a sterile dressing over the insertion site (D) is also important, but it usually comes before securing the cannula with tape to maintain a clean and sterile environment.
Question 5 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.
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