ATI RN
foundations of nursing test bank Questions
Question 1 of 5
A nurse is charting on a patient’s record. Whichaction will the nurse take that is accurate legally?
Correct Answer: A
Rationale: The correct answer is A: Charts legibly. This is accurate legally because clear and legible documentation is crucial for accurately conveying patient information, ensuring continuity of care, and meeting legal standards. Illegible handwriting can lead to errors in patient care and legal issues.
Choice B is incorrect as labeling a patient as "belligerent" without evidence can be perceived as unprofessional and potentially harmful to the patient.
Choice C is incorrect as writing an entry for another nurse can lead to inaccurate documentation and legal consequences.
Choice D is incorrect because using correction fluid can raise suspicion of tampering with records and compromise the integrity of the documentation.
Question 2 of 5
The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?
Correct Answer: D
Rationale: The correct answer is D: Mobility. A malignant breast tumor typically lacks mobility due to its fixed attachment to surrounding tissues. This characteristic is concerning for malignancy as it suggests invasive growth.
Incorrect answers:
A: Nontenderness - Tenderness does not reliably indicate malignancy or benignancy.
B: A size of 5 mm - Tumor size alone does not determine malignancy.
C: Softness and a regular shape - Malignant tumors are often firm and irregular in shape.
Question 3 of 5
A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding?
Correct Answer: A
Rationale: The correct answer is A because floaters are commonly caused by age-related changes in the vitreous humor of the eye, such as the formation of tiny fibers or clumps. These floaters are typically harmless and not a cause for concern.
Choice B is incorrect because glasses do not affect floaters in the eye.
Choice C is incorrect because floaters are not a primary symptom of glaucoma.
Choice D is incorrect because weakened ciliary muscles are not typically associated with floaters.
Therefore, the most appropriate interpretation is that seeing floaters is a normal aging process of the eye.
Question 4 of 5
An 86-year-old patient is experiencing uncontrollableleakage of urine with a strong desire to void and even leaks on the way to the toilet. Whichprioritynursing diagnosiswill the nurse include in the patient’s plan of care?
Correct Answer: B
Rationale:
Correct Answer: B - Urge urinary incontinence
Rationale:
1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence.
2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage.
Incorrect
Choices:
A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void.
C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis.
D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.
Question 5 of 5
A patient has just arrived to the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patients immediate postoperative recovery?
Correct Answer: C
Rationale: The correct answer is C: Assessing and addressing the patient's emotional needs. This should be prioritized because the patient has undergone a traumatic experience losing their eye due to a workplace accident. Emotions such as fear, anxiety, and grief are common postoperatively. Addressing these emotional needs is crucial for the patient's overall well-being and recovery. Options A, B, and D are important aspects of care but not the priority in this situation. Teaching about eye prostheses, depth perception, and medication regimen can be addressed once the patient's emotional needs are stabilized.