ATI RN
Nursing Process Quizlet Questions Questions
Question 1 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 2 of 5
While the patient�s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
Correct Answer: D
Rationale: The correct answer is D: Ask the patient about usual sleep patterns and the onset of having difficulty resting. Rationale: 1. Establish rapport: Asking about usual sleep patterns shows empathy and builds rapport. 2. Holistic assessment: Understanding sleep patterns helps identify potential issues beyond the leg cast. 3. Gather information: Knowing the onset of sleep difficulty can reveal underlying causes. 4. Patient-centered care: Addressing sleep concerns aligns with patient needs. Incorrect answers: A: Focusing solely on the leg and cast disregards the patient's holistic well-being. B: Documenting without addressing the patient's concern neglects the opportunity for intervention. C: Delaying assessment till the next shift can worsen the patient's condition and delay appropriate care.
Question 3 of 5
A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment?
Correct Answer: D
Rationale: The correct answer is D because interviewing a client suspected of being a victim of abuse involves critical thinking in assessment by gathering relevant information, analyzing the situation, and making informed decisions. This activity helps identify potential risks and ensures the client's safety. On the other hand, options A and C involve implementing orders and diagnosing conditions, respectively, which are more related to clinical decision-making rather than assessment. Option B focuses on education, which is not directly linked to assessment activities.
Question 4 of 5
Mr. Kawasaki, a 23-year old industrial worker, was burned severely in an industrial accident. He has second degree burns on his right leg and arm, and on his left leg. He has third degree burns on his left arm. The triage nurse, using the rule of nines, estimates the extent of burn as:
Correct Answer: C
Rationale: The rule of nines is a method used to estimate the extent of burns on a patient's body. According to this rule, each major body part is assigned a percentage value that represents the total body surface area (TBSA). In this case, Mr. Kawasaki has second-degree burns on his right leg and arm (9% each) and left leg (9%) and third-degree burns on his left arm (9%). Adding these percentages together, we get a total of 36%, which corresponds to the extent of burn on Mr. Kawasaki's body. Choice A (18%) is incorrect because it only considers one arm and one leg, neglecting the other affected areas. Choice B (45%) is incorrect as it overestimates the extent of burns by including additional body parts not affected. Choice D (54%) is also incorrect as it includes more body parts than those actually burned. Therefore, the correct answer is C (36%) as it accurately reflects the distribution of burns based
Question 5 of 5
A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?
Correct Answer: B
Rationale: The correct answer is B: soften the fecal mass and lubricate the walls of the rectum and colon. First, the oil retention enema helps soften the fecal mass, making it easier to pass. Second, the oil lubricates the walls of the rectum and colon, reducing friction and making the passage of stool smoother. This helps prepare the fecal impaction for removal during the subsequent cleansing enema. Choices A, C, and D are incorrect because they do not directly address the primary goal of softening the fecal mass and lubricating the walls of the intestines to facilitate the removal of the impaction.
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