ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client�s vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment?
Correct Answer: B
Rationale: The correct answer is B: Focused assessment. In this scenario, the nurse is continuously monitoring specific aspects such as vital signs, pupils, and orientation at regular intervals, which is characteristic of a focused assessment. This type of assessment allows the nurse to gather specific data related to the client's condition and respond promptly to any changes. A: Initial assessment is conducted upon admission to establish baseline data. C: Time-lapsed reassessment involves comparing current data to previous assessments over a longer period. D: Emergency assessment is performed in urgent situations to quickly identify life-threatening issues. By systematically assessing the client's vital signs, pupils, and orientation at frequent intervals, the nurse can provide timely and appropriate care in the intensive care unit setting.
Question 2 of 5
A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
Correct Answer: D
Rationale: The correct answer is D, as exercise and a weight reduction diet are essential components in managing type 2 diabetes. Exercise helps lower blood glucose levels and improves insulin sensitivity. Weight reduction reduces insulin resistance. Choice A is incorrect because maintaining blood glucose levels between 180-200mg/dl is too high and can lead to complications. Choice B is incorrect as complete smoking cessation is crucial for overall health and diabetes management. Choice C is incorrect because eye examinations should be done annually, not every 2 years, to monitor for diabetic retinopathy. In summary, choice D is the best option as it directly addresses the management of type 2 diabetes.
Question 3 of 5
. During the first 24 hours after a client is diagnosed with Addisonian crisis, which of the following should the nurse perform frequently?
Correct Answer: D
Rationale: The correct answer is D, assess vital signs, as it is crucial to monitor the client's hemodynamic stability and response to treatment during the critical initial 24 hours of Addisonian crisis. Vital signs such as blood pressure, heart rate, and respiratory rate provide valuable information about the client's condition and response to therapy. Weighing the client (choice A) and testing urine for ketones (choice C) may be important but not as immediately critical as monitoring vital signs. Administering oral hydrocortisone (choice B) is essential for treatment but does not require frequent administration within the first 24 hours.
Question 4 of 5
A patient has hand-foot syndrome related to his sickle cell anemia. What findings does the nurse expect to see as the patient is assessed?
Correct Answer: B
Rationale: The correct answer is B: Purplish discoloration of hands and feet. Hand-foot syndrome in sickle cell anemia is characterized by pain, swelling, and purplish discoloration of the hands and feet due to vaso-occlusive crisis. Unequal growth of fingers and toes (A), webbing between fingers and toes (C), and deformities of wrists and ankles (D) are not typical findings associated with hand-foot syndrome in sickle cell anemia.
Question 5 of 5
A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [retrovir]), 200mg PO every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
Correct Answer: C
Rationale: The correct answer is C: "Take zidovudine every 4 hours around the clock." Zidovudine is an antiretroviral medication used to treat HIV/AIDS. It is crucial for the client to adhere to the prescribed dosing schedule to maintain therapeutic blood levels. Taking the medication every 4 hours around the clock helps to ensure consistent levels in the body, maximizing its efficacy. Taking it with meals (choice A) or on an empty stomach (choice B) is not specifically indicated for zidovudine. Choice D is incorrect as taking OTC drugs without consulting a healthcare provider can lead to drug interactions or adverse effects. Hence, choice C is the most appropriate instruction to ensure the client benefits from the medication.
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