ATI RN
ATI RN Custom Exams Set 3
1. Which of the following describes the four-step method of assessment, planning, implementation, and evaluation?
- A. It is a problem-focused process of continued nursing care
- B. It is an open-ended process of continued nursing care
- C. It is a circular process of continued nursing care
- D. It is a trial-and-error process of continued nursing care
Correct answer: C
Rationale: The correct answer is C: 'It is a circular process of continued nursing care.' The four-step method of assessment, planning, implementation, and evaluation is a continuous and cyclical process in nursing care. Choice A is incorrect because the method is not solely problem-focused but involves multiple steps. Choice B is incorrect as it does not capture the structured nature of the four-step method. Choice D is incorrect as it implies a random approach rather than a systematic and organized process.
2. Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?
- A. Platelet count
- B. Reticulocyte count
- C. Total lymphocyte count
- D. Absolute neutrophil count
Correct answer: D
Rationale: The correct answer is D, Absolute neutrophil count. Filgrastim (Neupogen) works by stimulating the production and function of neutrophils. Therefore, monitoring the Absolute neutrophil count is crucial to assess the effectiveness of filgrastim in increasing neutrophil levels. Choices A, B, and C are incorrect because platelet count, reticulocyte count, and total lymphocyte count do not directly reflect the effectiveness of filgrastim in increasing neutrophils, which are essential in fighting infections during chemotherapy.
3. A client diagnosed with borderline personality disorder tells the nurse, 'You are the only one who understands me. The other nurses don't care about me.' Which of the following responses should the nurse make?
- A. Why do you feel that way?
- B. The other nurses care about you too.
- C. You shouldn't say things like that.
- D. I think you are overreacting.
Correct answer: B
Rationale: The correct response is to acknowledge the client's feelings and provide support while also emphasizing that all staff members care about the client's well-being. Choice A does not acknowledge the client's emotions and may come across as dismissive. Choice C invalidates the client's feelings and may make the client feel misunderstood. Choice D minimizes the client's emotions, which can lead to a breakdown in therapeutic communication. Therefore, option B is the most appropriate response as it validates the client's feelings while reinforcing the idea that the entire healthcare team is supportive.
4. A client with breast cancer is receiving cyclophosphamide. Which of the following findings should the nurse monitor?
- A. Hypertension
- B. Hyperglycemia
- C. Ototoxicity
- D. Hemorrhagic cystitis
Correct answer: D
Rationale: The nurse should monitor the client for hemorrhagic cystitis when receiving cyclophosphamide due to its potential to cause bladder irritation and lead to this serious adverse effect. It is essential to assess for symptoms such as hematuria, dysuria, and flank pain. Monitoring for hypertension, hyperglycemia, and ototoxicity is not directly related to the side effects of cyclophosphamide.
5. During the nurse’s initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. What action should the nurse take?
- A. Reassess the child in 15 minutes to see if the pain rating has changed
- B. Administer the prescribed analgesic
- C. Do nothing since the child appears to be resting
- D. Ask the child’s parents if they think the child is hurting
Correct answer: B
Rationale: Pain management should be based on the child’s report of pain, regardless of their activity level. Administering the prescribed analgesic is the appropriate action. Reassessing the child in 15 minutes without providing immediate pain relief may not be in the child's best interest. Doing nothing since the child appears to be resting may lead to inadequate pain management. Asking the child’s parents if they think the child is hurting does not replace the need for direct assessment and intervention by the nurse.