ATI RN
Multi Dimensional Care | Final Exam
1. What is correct about a nursing diagnosis?
- A. It is a human response to disease, injury, or other stressors.
- B. It remains constant as long as the disease is present.
- C. It is a way to identify pathology.
- D. It is a disease, illness, or injury.
Correct answer: A
Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.
2. What is the best intervention for a patient with respiratory distress?
- A. Administer oxygen
- B. Administer bronchodilators
- C. Administer IV fluids
- D. Administer corticosteroids
Correct answer: A
Rationale: The correct answer is to administer oxygen. In respiratory distress, the priority intervention is to improve oxygenation. Administering oxygen helps increase the oxygen levels in the blood, supporting respiratory function. While bronchodilators may be used in specific respiratory conditions like asthma or COPD, they are not the primary intervention for respiratory distress. IV fluids are not indicated as the initial treatment for respiratory distress unless there is an underlying cause such as dehydration. Corticosteroids may be used in certain respiratory conditions to reduce inflammation, but they are not the first-line intervention for acute respiratory distress.
3. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?
- A. Less than 30 ml/hour
- B. 64 ml in 2 hours
- C. 90 ml in 3 hours
- D. 125 ml in 4 hours
Correct answer: A
Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.
4. What outcome has been shown to be a benefit of breastfeeding that directly impacts the mother?
- A. conserving calcium stores
- B. contracting the uterus
- C. protecting against future hypertension
- D. speeding the resumption of ovulation
Correct answer: B
Rationale: The correct answer is B, contracting the uterus. Breastfeeding helps contract the uterus after childbirth, reducing postpartum bleeding and helping the uterus return to its pre-pregnancy size more quickly. Choices A, C, and D are incorrect because conserving calcium stores, protecting against future hypertension, and speeding the resumption of ovulation are not direct benefits of breastfeeding to the mother.
5. What procedure involves inserting a flexible tube with a light and camera into the airways to examine the lungs and collect samples?
- A. Bronchoscopy
- B. Thoracentesis
- C. Lung biopsy
- D. Chest X-ray
Correct answer: A
Rationale: The correct answer is A: Bronchoscopy. Bronchoscopy is a procedure that entails inserting a flexible tube with a light and camera into the airways to examine the lungs and collect tissue or fluid samples. This procedure is commonly performed to diagnose lung conditions such as infections, tumors, or obstructions. Choice B, thoracentesis, involves inserting a needle into the pleural space to remove fluid for diagnostic or therapeutic purposes related to the lungs or pleura, not the airways. Choice C, lung biopsy, typically involves obtaining tissue samples from the lungs for further examination, not directly visualizing the airways. Choice D, chest X-ray, is a diagnostic imaging technique that uses radiation to create images of the chest area, providing a different type of information compared to bronchoscopy.
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