Nursing Process Final Exam Questions

Questions 71

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Nursing Process Final Exam Questions Questions

Question 1 of 5

The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?

Correct Answer: C

Rationale: The correct answer is C: Take piroxicam with food or oral antacid. This instruction helps to reduce GI irritation by providing a protective barrier for the stomach lining. Piroxicam is known to cause GI upset due to its effect on prostaglandin synthesis. Taking it with food or an antacid can help minimize this side effect. Choice A (Space the administration every 4 hours) does not address the issue of GI irritation and is not a recommended strategy for preventing this side effect. Choice B (Use the drug for a short time only) is not a direct intervention to prevent GI upset and does not provide guidance on how to manage the side effect when taking the medication. Choice D (Decrease the piroxicam dosage) may not be necessary if the client can manage the side effects with the simple intervention of taking it with food or an antacid.

Question 2 of 5

Which of the following would the nurse identify as an abnormal finding?

Correct Answer: C

Rationale: The nurse would identify platelets at 115,000/ul as an abnormal finding because it is below the normal range of 150,000-450,000/ul. Low platelet count can lead to increased bleeding risk. RBC count and hematocrit levels are within normal ranges, making them normal findings. Option D is incorrect as platelets are abnormal.

Question 3 of 5

Which of the ff is the most severe complication among clients with allergies, regardless of type?

Correct Answer: B

Rationale: The correct answer is B, anaphylactic shock and angioedema, as it is the most severe complication of allergies and can be life-threatening. Anaphylactic shock can lead to airway constriction, severe drop in blood pressure, and organ failure. Angioedema can cause swelling of the face, lips, and throat, leading to difficulty breathing. Bronchitis (A) is a respiratory condition that can occur due to allergies but is not typically life-threatening. Cardiac arrest (C) is a serious complication but not directly related to allergies. Asthma and nasal polyps (D) are common allergic conditions but are not as immediately life-threatening as anaphylactic shock.

Question 4 of 5

A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:

Correct Answer: D

Rationale: The correct answer is D, the Western blot test with ELISA. First, ELISA is used as a screening test for HIV antibodies. If positive, a confirmatory test like Western blot is needed to detect specific antibodies. Western blot is highly specific and confirms the presence of HIV antibodies. E-rosette immunofluorescence is not typically used for HIV diagnosis. Quantification of T-lymphocytes is used to monitor disease progression in HIV but does not confirm HIV infection. ELISA alone is not confirmatory; it needs to be followed by a more specific test like Western blot.

Question 5 of 5

A client was brought to the school clinic wuth severe, constant, localized abdominal pain. Abdominal muscles are rigid, and rebound tenderness is present. Peritonitis is suspected. The client is hypotensive and tachycardic. The nursing diagnosis most appropriate to the client�s signs/symptoms is:

Correct Answer: A

Rationale: The correct answer is A: fluid volume deficit related to depletion of intravascular volume. Peritonitis causes inflammation of the peritoneum, leading to fluid shifting into the peritoneal cavity, causing hypovolemia. Hypotension and tachycardia are signs of decreased intravascular volume. Rigid abdominal muscles and rebound tenderness indicate peritoneal irritation. Choice B is incorrect because elevated ammonia levels are not associated with the client's symptoms. Choice C is incorrect because increased peristalsis does not explain the client's hypotension and tachycardia. Choice D is incorrect because malabsorption does not align with the client's acute presentation of severe abdominal pain and peritonitis.

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