ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 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.
Question 2 of 5
Aling Nena, 68 years old, had a MVA and underwent surgery for hip fracture. Two days post-surgery, she suddenly complained of chest heaviness despite the absence of cardiac history. What is the nursing priority?
Correct Answer: C
Rationale: The correct answer is C: administer oxygen via face mask. Given Aling Nena's sudden chest heaviness post-surgery, oxygen administration is the priority to ensure adequate oxygenation. This can help rule out potential respiratory issues or hypoxemia, which are common post-operatively. Providing oxygen promptly can prevent further complications such as respiratory distress or cardiac compromise. Documenting the pain characteristics (choice A) can be done after ensuring immediate physiological needs are met. Offering analgesics (choice B) without confirming the underlying cause can mask symptoms and delay appropriate interventions. Informing the physician (choice D) is important but not as urgent as addressing potential respiratory compromise.
Question 3 of 5
Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the
Correct Answer: D
Rationale: The correct answer is D: Eight Cranial Nerve (Vestibulocochlear). Mr. Reyea's complaint of hearing ringing noises indicates a potential issue with his auditory function, which is primarily governed by the Vestibulocochlear nerve. This nerve is responsible for transmitting sound and balance information from the inner ear to the brain. The other choices, A: Frontal lobe, B: Six cranial nerve (abducent), and C: Occipital lobe, are not directly associated with auditory function or the perception of ringing noises in the ear.
Question 4 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 5 of 5
For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
Correct Answer: A
Rationale: The correct answer is A. Prednisone is a corticosteroid that can cause adverse reactions such as increased weight due to fluid retention, hypertension due to sodium retention, and insomnia due to its stimulating effects. Vaginal bleeding, jaundice, inflammation, stupor, breast lumps, pain, dyspnea, numbness, and headache are not commonly associated with prednisone use. Monitoring for weight changes, blood pressure, and sleep patterns is essential when administering prednisone to a client with rheumatoid arthritis for early detection and management of adverse reactions.
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