Complete Question Bank

ATI RN · Nursing Process · Nursing Process Test Questions

Full Question & Rationale Repository

Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

A client with neuromuscular disorder is receiving intensive nursing care. The client is likely to face the risk for impaired skin integrity. Which of the ff must the nurse ensure to prevent skin breakdown in the client?

A. Prevent strenuous exercises by the client

B. Use pressure relieving devices when the client is in bed

C. Place the client in Fowler's position

D. Avoid giving daily baths with soaps to the client

Expert Explanatory Rationale

Correct Answer: Use pressure relieving devices when the client is in bed

Question 2 of 5

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?

A. Gordon's Functional Health Patterns

B. Activity-exercise pattern assessment

C. General to specific assessment

D. Problem-oriented assessment

Expert Explanatory Rationale

Correct Answer: General to specific assessment

Question 3 of 5

Which of the following best defines the process of evaluating a nursing intervention?

A. Collecting data to determine if goals were achieved

B. Identifying nursing diagnoses for new problems

C. Adjusting the care plan to include collaborative interventions

D. Performing client care tasks as per protocol

Expert Explanatory Rationale

Correct Answer: Collecting data to determine if goals were achieved

Question 4 of 5

Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?

A. massive ascites formation

B. fluid volume excess

C. increased serum ammonia levels

D. altered clotting mechanism

Expert Explanatory Rationale

Correct Answer: increased serum ammonia levels

Question 5 of 5

Which action by the nurse is appropriate?

A. Observe the patient for abnormal bleeding.

B. Notify the physician and expect an order to increase the warfarin dose.

C. Advise the patient to double today's dose of warfarin.

D. Administer Vit. K per protocol.

Expert Explanatory Rationale

Correct Answer: Observe the patient for abnormal bleeding.