Nursing Process Practice Questions Quizlet

Questions 71

ATI RN

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Nursing Process Practice Questions Quizlet Questions

Question 1 of 5

A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)?

Correct Answer: B

Rationale: The correct answer is B because red, open sores on the oral mucosa are a common sign of stomatitis, which can be caused by chemotherapy. Stomatitis is characterized by inflammation and ulceration of the mouth lining. The other choices are incorrect because: A: White, cottage cheese-like patches are indicative of oral thrush, a fungal infection. C: Rust-colored sputum may indicate a respiratory condition or infection, not stomatitis. D: Yellow tooth discoloration is not typically associated with stomatitis, but can be caused by various factors such as poor oral hygiene or certain foods.

Question 2 of 5

Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?

Correct Answer: D

Rationale: The correct answer is D: Patency of airway and adequacy of respiration. During the acute stage of an unconscious patient like Mr. Franco, ensuring the airway is open and that breathing is adequate is the top priority to maintain oxygenation and prevent complications like hypoxia. This assessment is crucial for immediate intervention and can be life-saving. A: Level of awareness and response to pain may provide important information but is secondary to ensuring a patent airway and adequate breathing in an unconscious patient. B: Pupillary reflexes and response to sensory stimuli are important neurological assessments, but airway and breathing take precedence in the acute stage to maintain vital functions. C: Coherence and sense of hearing are not as critical as assessing and maintaining the airway and breathing in an unconscious patient.

Question 3 of 5

A client with cancer that has metastazised to the liver is started on chemotherapy- His physician has specified divided doses of the antimetabolite. The client asks why he could take the drug in divided doses. The appropriate response is:

Correct Answer: C

Rationale: The correct answer is C: "Divided doses produce greater cytotoxic effects on the diseased cells." Dividing the doses of the antimetabolite allows for more consistent levels of the drug in the bloodstream, ensuring sustained exposure to the cancer cells. This continuous exposure enhances the drug's cytotoxic effects, increasing its efficacy in targeting and destroying the diseased cells. Options A and B provide vague or incorrect information, while option D is misleading as antimetabolites do not prevent cell division, but rather disrupt DNA synthesis.

Question 4 of 5

During the physical assessment, the nurse recalls that the areas most frequently affected by multiple sclerosis are the:

Correct Answer: C

Rationale: Rationale for Choice C (Correct Answer): 1. Multiple sclerosis (MS) commonly affects the optic nerve and chiasm. 2. MS is characterized by demyelination of nerves, leading to visual disturbances. 3. Optic nerve involvement results in vision problems, such as blurred vision. 4. Chiasm involvement can cause visual field deficits and color perception changes. Summary of Other Choices: A: Lateral, 3rd, and 4th ventricles - Incorrect. MS primarily affects the central nervous system, not ventricles. B: Pons, medulla, and cerebral peduncles - Incorrect. While these areas are part of the brainstem, they are not commonly affected in MS. D: Above areas - Incorrect. This choice is vague and does not specify any specific areas affected by MS.

Question 5 of 5

A client has undergone a nephrectomy and is placed under observation after a urethral catheter insertion. As part of the nursing care plan, the nurse records the color of drainage from each tube and catheter. Which of the ff is the reason for this?

Correct Answer: B

Rationale: The correct answer is B: To provide a means for further comparison and evaluation. By recording the color of drainage from each tube and catheter, the nurse can monitor changes over time, assess for any abnormalities, and evaluate the effectiveness of treatment. This helps in detecting complications early and making informed decisions. Rationale for other choices: A: To restore and maintain intravascular volume - Monitoring drainage color does not directly relate to intravascular volume status. C: To avoid interference with wound drainage - Monitoring drainage color does not prevent interference with wound drainage. D: To prevent pain related to obstruction - Monitoring drainage color does not directly prevent pain related to obstruction.

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