ATI RN
Nursing Process Test Questions Questions
Question 1 of 5
After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?
Correct Answer: B
Rationale: The correct answer is B. Administering epinephrine is the first-line treatment for anaphylactic shock to reverse hypotension and bronchoconstriction. Intubation may be necessary if airway compromise occurs despite epinephrine. Paging an anesthesiologist (A) is not the priority. Administering penicillin antidote (C) is not indicated in anaphylaxis. Inserting a urinary catheter and infusing IV fluids (D) may be necessary later but not the priority in managing anaphylactic shock.
Question 2 of 5
A client has been diagnosed with renal failure and is admitted for dialysis. Which of the ff is the nurse�s responsibility as the client undergone dialysis?
Correct Answer: C
Rationale: The correct answer is C: Weighing the client before and after the procedure. This is crucial as it helps monitor fluid removal during dialysis, ensuring the process is effective and safe. Weighing helps determine if the correct amount of fluid has been removed. A: Keeping dialysis supplies in a clean area is important for infection control but not a direct responsibility during the procedure. B: Inspecting the catheter insertion site for signs of infection is essential for monitoring the site's health but not a direct responsibility during dialysis. D: Washing hands before and after handling the catheter is a general infection control measure but not specific to the dialysis procedure itself.
Question 3 of 5
The physician prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a client with type 2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and exercise. Which medication instruction should the nurse provide?
Correct Answer: A
Rationale: The correct answer is A: �Be sure to take glipizide 30 minutes before meals.� This instruction is correct because glipizide is an oral antidiabetic agent that works best when taken before meals to help control blood glucose levels. Taking it before meals allows the medication to coincide with the body's natural insulin response to food intake, thereby improving its effectiveness. Choice B is incorrect because glipizide does not typically cause low serum sodium levels, so there is no need for monthly sodium level checks. Choice C is incorrect because it is essential for the client to continue monitoring their blood glucose levels even after starting glipizide to ensure the medication is working effectively. Choice D is incorrect because taking glipizide after a meal will not optimize its effectiveness in controlling blood glucose levels.
Question 4 of 5
When performing a neurological examination on Mr. RR, which of the following would not be considered an important or useful part of the examination?
Correct Answer: D
Rationale: The correct answer is D because pupil size is not typically a part of a routine neurological examination. A: Eye movements are assessed to evaluate cranial nerve functions. B: Reflexes help determine the integrity of the spinal cord and peripheral nervous system. C: Nuchal rigidity is important to assess for signs of meningitis or other neurological conditions. In contrast, pupil size is more relevant in ophthalmological examinations or when assessing response to specific medications affecting the pupil size.
Question 5 of 5
Which of the ff. statements does the nurse understand is true concerning air conduction of sound in the ear?
Correct Answer: B
Rationale: The correct answer is B because air conduction is less efficient than bone conduction due to the sound waves traveling through the air in the ear canal, which can be hindered by factors like blockages or obstructions. This results in a weaker and less clear sound transmission compared to bone conduction, where sound waves are transmitted directly through the bones of the skull, bypassing any potential obstructions in the ear canal. Incorrect choices: A: This statement is incorrect as air conduction of sound in the ear is not caused by the vibration of bones in the skull. C: This statement is incorrect as air conduction is typically heard for a shorter duration than bone conduction. D: This statement is incorrect as air conduction of sound in the ear is not caused by the transmission of heat through the air, but rather by sound waves traveling through the ear canal.
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