ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 5
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
Correct Answer: C
Rationale: The correct answer is C: Bluish urine. During lymphangiography, a contrast dye is injected into the lymphatic vessels, which can be excreted through the urine, causing it to appear bluish temporarily. This change is harmless and resolves on its own. Incorrect Answers: A: Purplish stools - This is not a common side effect of lymphangiography. B: Redness of the upper part of the feet - Redness is not typically associated with this procedure. D: Coldness of the soles - Coldness is not a known temporary change resulting from lymphangiography.
Question 2 of 5
After a Whippie procedure for cancer of the pancreas, a client is to receive the following intravenous (IV) fluids over 24 hours; 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. The nurse calculates that the clients IV fluid intake Tor 24 hours will be:
Correct Answer: D
Rationale: The correct answer is D (3750ml) because the client will receive 1000ml D5W + 500ml normal saline + 1500ml D5NS + 50ml antibiotic every 8 hours x 3 times in 24 hours (50ml x 3 = 150ml). Adding these together gives a total of 1000ml + 500ml + 1500ml + 150ml = 3150ml. Therefore, the client's IV fluid intake for 24 hours will be 3150ml.
Question 3 of 5
Which nursing intervention is most appropriate for a client with multiple myeloma?
Correct Answer: D
Rationale: The correct answer is D: Preventing bone injury. In multiple myeloma, bone lesions are common due to bone destruction by abnormal plasma cells. Preventing bone injury is crucial to avoid fractures and bone pain. This can be achieved through careful handling, fall prevention, and avoiding activities that may increase the risk of bone damage. Monitoring respiratory status (A) is not the priority in multiple myeloma. Balancing rest and activity (B) is important but not as critical as preventing bone injury. Restricting fluid intake (C) is not typically necessary unless there are specific indications like renal issues.
Question 4 of 5
Place the following four nursing actions for the new laryngectomee in correct order of priority? i.Assist with ambulation ii.Set up a visit from a well-adjusted laryngectomee iii.Maintain a patent airway iv.Control postoperative pain
Correct Answer: C
Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.
Question 5 of 5
Rehabilitation plans for Mr. Gabatan;
Correct Answer: B
Rationale: The correct answer is B because rehabilitation plans should be considered and planned for early in Mr. Gabatan's care to ensure the best outcomes. By addressing rehabilitation early, healthcare professionals can tailor interventions to his specific needs, promote independence, and prevent complications. This proactive approach enhances Mr. Gabatan's quality of life and functional abilities. Choices A, C, and D are incorrect: A: Leaving rehabilitation plans solely up to Mr. Gabatan and his family may not ensure comprehensive care and could lead to delays or inadequate support. C: Assuming Mr. Gabatan will return to former activities without proper rehabilitation assessment and planning overlooks potential limitations and needs. D: Assuming Mr. Gabatan will not be able to work again without proper rehabilitation evaluation and interventions may limit his potential for recovery and independence.
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