ATI RN
foundations of nursing test bank Questions
Question 1 of 5
A nurse is sitting at the patient’s bedside takinga nursing history. Which zone of personal space is the nurse using?
Correct Answer: B
Rationale: The nurse sitting at the patient's bedside is using the personal zone of personal space, which ranges from 18 inches to 4 feet. This distance allows for a close interaction suitable for taking a nursing history while maintaining a professional yet personal connection. The socio-consultative zone (
A) is 4-12 feet, more appropriate for professional interactions. The intimate zone (
C) is 0-18 inches, too close for an initial nursing history. The public zone (
D) is 12 feet or more, too distant for a personal conversation.
Question 2 of 5
The nurse is planning care for a group of patients.Which task will the nurse assign to the nursing assistive personnel (NAP)?
Correct Answer: C
Rationale:
Correct
Answer: C - Administering an enema
Rationale: Administering an enema is a task that can be safely delegated to nursing assistive personnel (NAP) as it is within their scope of practice and does not require the specialized knowledge and skills of a registered nurse. NAP can be trained to perform enema administration safely and effectively, under the supervision of a nurse. This task involves following a specific procedure and does not require clinical judgment or decision-making.
Summary of other choices:
A: Performing the first postoperative pouch change - This task involves wound care and assessment, which require the expertise of a registered nurse.
B: Maintaining a nasogastric tube - This task involves ongoing assessment, monitoring for complications, and adjustments, which are responsibilities of a registered nurse.
D: Digitally removing stool - This task involves invasive procedures and assessment, which are beyond the scope of practice for nursing assistive personnel.
Question 3 of 5
A patient with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the patient about this treatment?
Correct Answer: B
Rationale:
Step 1: Immunotherapy injections can cause allergic reactions.
Step 2: Monitoring post-injection is crucial to detect and manage any potential adverse reactions promptly.
Step 3: Staying in the clinic for 30 minutes allows for immediate intervention if needed.
Step 4: This ensures patient safety and reduces the risk of severe reactions.
Summary:
A: Epinephrine is not typically given before immunotherapy injections.
C: Therapeutic response may take longer than 3 months to show.
D: Immunotherapy is usually given via subcutaneous route, not intravenous.
Question 4 of 5
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
Correct Answer: A
Rationale: The correct answer is A: Utilize a pressure-reducing mattress. This intervention is crucial for preventing pressure ulcers in patients at risk for impaired skin integrity, such as those with HIV. By redistributing pressure, a pressure-reducing mattress helps to alleviate pressure on vulnerable areas, reducing the risk of skin breakdown. Limiting physical activity (
B) can lead to muscle atrophy and worsen skin integrity. Applying antibiotic ointment (
C) may not address the root cause of skin breakdown. Avoiding synthetic fabrics (
D) may be helpful in some cases, but it is not as effective as using a pressure-reducing mattress.
Question 5 of 5
A nurse is teaching a patient about proteins that must be obtained through the diet and cannot be synthesized in the body. Which term used by the patient indicates teaching is successful?
Correct Answer: D
Rationale:
Rationale:
1. Indispensable amino acids, also known as essential amino acids, must be obtained through the diet as the body cannot synthesize them.
2. Amino acids are the building blocks of proteins, so mentioning "indispensable amino acids" indicates understanding of essential dietary proteins.
3. Triglycerides are fats, not proteins, and not related to essential amino acids.
4. Dispensable amino acids can be synthesized by the body, so mentioning them would not indicate understanding of essential proteins.