ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 5
A client has the following blood lab values: platelets 50,000/ul, RBC�s 3.5 (X 106), hemoglobin 10 g/dl, hematocrit 30 percent, WBCs 10,000/ul. Which nursing instruction should be included in the teaching plan?
Correct Answer: A
Rationale: The correct answer is A: Bleeding precautions. With low platelets (50,000/ul), the client is at risk for bleeding. Platelets help with blood clotting, so precautions to prevent bleeding are essential. This includes avoiding activities that can cause injury, using a soft toothbrush, and reporting any signs of bleeding. Summary: B: Isolation to prevent infection - This is not related to the client's lab values. C: Seizure precautions - Not relevant to the client's lab values. D: Control of pain with analgesics - Pain management is not the priority given the client's lab values indicating a risk of bleeding.
Question 2 of 5
Which of the ff blood vessel is commonly affected by thrombophlebitis?
Correct Answer: C
Rationale: The correct answer is C, veins deep in the lower extremities, due to stasis and immobility in the legs causing blood to pool and predispose to thrombus formation. This is known as deep vein thrombosis (DVT). Veins deep in the upper extremities (A) are less commonly affected. The popliteal vein of the leg (B) is a common site for DVT, but it is not the most commonly affected. Veins connected to the heart (D) are arteries, not veins, and are not typically involved in thrombophlebitis.
Question 3 of 5
The nurse is preparing to administer a unit of blood to a client�s who�s anemic. After its removal from the refrigerator, the blood should be administered within:
Correct Answer: C
Rationale: The correct answer is C: 2 hours. Blood should be administered within 30 minutes to 4 hours after removal from the refrigerator to prevent bacterial growth and maintain its efficacy. Option C falls within this timeframe, ensuring safety and effectiveness. Option A (1 hour) is too short, while option B (4 hours) and option D (6 hours) exceed the recommended timeframe, increasing the risk of bacterial contamination and compromising the quality of the blood product.
Question 4 of 5
A patient with a brain tumor is admitted to the medical unit to begin radiation treatments. Which nursing action should take priority?
Correct Answer: C
Rationale: The correct answer is C because assessing the patient's pain level is the priority when caring for a patient with a brain tumor about to begin radiation treatments. Pain management is crucial in providing comfort and ensuring the patient's well-being during treatment. Teaching the patient about what to expect and addressing any pain promptly are essential steps in delivering effective care. Padding the side rails (choice A) is important for patient safety, but it is not the priority in this situation. Isolating the patient (choice D) is unnecessary unless there is a specific medical indication. Teaching the patient what to expect (choice B) is important but assessing and managing pain take precedence to ensure the patient's comfort and safety during treatment.
Question 5 of 5
Which finding is an early indicator of bladder cancer?
Correct Answer: A
Rationale: The correct answer is A: Painless hematuria. This is an early indicator of bladder cancer because blood in the urine without pain is a common symptom in the early stages of the disease. Nocturia (B), frequent urination at night, is more commonly associated with urinary tract infections or benign prostatic hyperplasia. Occasional polyuria (C), excessive urination, can be a symptom of diabetes or kidney disease. Dysuria (D), painful urination, is more indicative of urinary tract infections or urethritis. Therefore, painless hematuria is the most specific early indicator of bladder cancer among the choices provided.
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