Fundamentals of Nursing Nursing Process Questions

Questions 75

ATI RN

ATI RN Test Bank

Fundamentals of Nursing Nursing Process Questions Questions

Question 1 of 5

A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (sub-arachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist�s instructions. Why does the client require special positioning for this type of anesthesia?

Correct Answer: B

Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage. 1. Positioning is crucial to prevent CSF leakage as the spinal block is administered into the sub-arachnoid space where CSF is present. 2. Incorrect Answers: A: Positioning is not related to preventing confusion in this context. C: Seizures are not typically associated with spinal block anesthesia. D: Cardiac arrhythmias are not directly impacted by the client's positioning for a spinal block.

Question 2 of 5

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. This involves analyzing assessment data, utilizing critical thinking skills to identify patient problems, and formulating nursing diagnoses. Diagnostic reasoning is the process of synthesizing information to make clinical judgments and determine appropriate interventions. A: Assigning clinical cues - Incorrect. This refers to identifying observable signs or symptoms, not the process of developing a nursing diagnosis. B: Defining characteristics - Incorrect. This term is often used to describe the symptoms or manifestations associated with a nursing diagnosis, not the process of deriving the diagnosis. D: Diagnostic labeling - Incorrect. This is the final step in the nursing diagnosis process where the nurse assigns a label to the identified patient problem, not the process of critical thinking and data analysis.

Question 3 of 5

A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which �related-to� phrase should the nurse add?

Correct Answer: A

Rationale: The correct answer is A: Related to bone demineralization resulting in pathologic fractures. In chronic hyperparathyroidism, there is excessive release of parathyroid hormone, leading to increased bone resorption and calcium release from bones, causing bone demineralization and weakening. This puts the client at risk for pathologic fractures. Choice B is incorrect because exhaustion is not a direct consequence of chronic hyperparathyroidism. Choice C is incorrect as edema and dry skin are not typical manifestations of hyperparathyroidism. Choice D is incorrect because tetany is more commonly associated with hypocalcemia, which is not a typical finding in hyperparathyroidism.

Question 4 of 5

Rodolfo, an 85 year old, is admitted for comtinuous cramping pain as the result of intermittent claudication. When conducting an initial physical assessment, the nurse is unable to palpate the pedal pulses. Which of the following actions should the nurse take first?

Correct Answer: D

Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action. Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.

Question 5 of 5

A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?

Correct Answer: D

Rationale: The correct answer is D: Leucovorin. Leucovorin is given during methotrexate therapy to protect normal cells by acting as a rescue agent that helps to reduce the toxic effects of methotrexate. It works by enhancing the efficacy of methotrexate in cancer cells while reducing its toxicity in normal cells. Probenecid (A) is not used to protect normal cells during methotrexate therapy. Cytarabine (B) and Thioguanine (C) are other chemotherapeutic agents and are not typically given to protect normal cells during methotrexate therapy.

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