ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
A 23-year-old woman comes to the free clinic stating I think I have a lump in my breast. Do I have cancer? The nurse instructs the patient that a diagnosis of breast cancer is confirmed by what?
Correct Answer: B
Rationale: The correct answer is B: Mammography. Mammography is the gold standard for diagnosing breast cancer as it can detect abnormalities such as lumps or tumors in the breast tissue. It provides detailed images that can help healthcare providers identify suspicious areas that may require further testing or biopsy. Supervised breast self-examination (choice A) is important for early detection but is not a diagnostic tool. Fine-needle aspiration (choice C) is a procedure used to obtain a sample of cells for further analysis but is not definitive for diagnosing breast cancer. Chest x-ray (choice D) is used to evaluate the lungs and heart, not the breast tissue for cancer.
Question 2 of 9
A nurse is a member of an interdisciplinary teamthat uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?
Correct Answer: C
Rationale: The correct answer is C: Document the variance in the patient’s record. By documenting the variance in the patient's record, the nurse can provide a clear record of the deviation from the critical pathway. This documentation is essential for tracking the patient's progress accurately and identifying potential issues that may require intervention. It allows for proper communication among the interdisciplinary team and ensures that everyone is aware of the deviation. Choice A is incorrect because adding data to the problem list may not provide a comprehensive record of the variance. Choice B is incorrect because focusing on charting using the DAR format does not address the deviation from the critical pathway. Choice D is incorrect because reporting a positive variance in the next team meeting may not accurately reflect the patient's actual progress and may lead to miscommunication within the team.
Question 3 of 9
Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient?
Correct Answer: C
Rationale: The correct answer is C: Reduce environmental noise and distractions before communicating. This intervention is most likely to facilitate effective communication with a hearing-impaired patient because it creates an optimal environment for the patient to better focus on the communication. By reducing noise and distractions, the patient can more easily concentrate on the conversation and lip reading, if needed. This approach demonstrates sensitivity to the patient's needs and enhances the chances of successful communication. The other choices are incorrect because: A: Asking the patient to repeat what was said may cause frustration and does not address the environmental factors that can hinder communication. B: Standing directly in front of the patient to facilitate lip reading may help, but it does not address the impact of environmental noise and distractions on communication. D: Raising the voice to project sound at a higher frequency is not effective as it can distort speech and may not necessarily improve understanding for a hearing-impaired patient.
Question 4 of 9
During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?
Correct Answer: D
Rationale: The correct answer is D: Pneumocystis pneumonia. This is the most common life-threatening infection in HIV-positive patients with low CD4+ counts. Pneumocystis pneumonia is caused by the opportunistic pathogen Pneumocystis jirovecii, which can lead to severe respiratory distress and mortality in immunocompromised individuals. The other choices, A: Salmonella infection, B: Mycobacterium tuberculosis, and C: Clostridium difficile, can also cause infections in HIV-positive patients, but they are not as commonly associated with life-threatening complications in this population compared to Pneumocystis pneumonia. It is crucial for the nurse to prioritize assessment for signs and symptoms of Pneumocystis pneumonia in this patient to promptly intervene and prevent further complications.
Question 5 of 9
After the completion of testing, a childs allergies have been attributed to her familys cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action?
Correct Answer: A
Rationale: The correct answer is A: Removing the cat from the family's home. This is the most effective way to prevent allergic reactions in the child. By removing the source of allergens (cat), the child will be exposed to fewer allergens, leading to a reduction in symptoms. B: Administering OTC antihistamines treats symptoms but does not address the underlying cause of the allergy. C: Keeping the cat restricted from the child's bedroom helps reduce exposure, but allergens can still spread throughout the house. D: Maximizing airflow may help reduce allergens in the air but does not eliminate the source of the allergy.
Question 6 of 9
A clinic nurse is providing patient education prior to a patients scheduled palliative radiotherapy to her spine. At the completion of the patient teaching, the patient continues to ask the same questions that the nurse has already addressed. What is the plausible conclusion that the nurse should draw from this?
Correct Answer: D
Rationale: The correct answer is D. The plausible conclusion the nurse should draw is that the patient has not achieved the desired learning outcomes. 1. The patient's repeated questions indicate a lack of understanding despite the nurse's teaching efforts. 2. This suggests that the patient has not grasped the information provided. 3. It does not necessarily mean the patient is not listening effectively, noncompliant, or has low intelligence. 4. The focus should be on reassessing the teaching methods and providing additional support to help the patient achieve the desired learning outcomes.
Question 7 of 9
A patient has been diagnosed with glaucoma and the nurse is preparing health education regarding the patients medication regimen. The patient states that she is eager to beat this disease and looks forward to the time that she will no longer require medication. How should the nurse best respond?
Correct Answer: B
Rationale: The correct answer is B: In fact, glaucoma usually requires lifelong treatment with medications. 1. Glaucoma is a chronic condition characterized by increased intraocular pressure. 2. Lifelong treatment is usually necessary to manage intraocular pressure and prevent vision loss. 3. Stopping medication prematurely can lead to worsening of the condition. 4. Therefore, the nurse should educate the patient about the need for ongoing medication to manage glaucoma effectively. Summary: A: Incorrect. Having a positive attitude is beneficial, but it does not shorten the duration of glaucoma treatment. C: Incorrect. The target intraocular pressure is usually below 21 mm Hg, not 50 mm Hg. D: Incorrect. Glaucoma treatment is typically long-term, not limited to 6 months.
Question 8 of 9
The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse’s next action?
Correct Answer: D
Rationale: The correct answer is D: Use electronic fetal surveillance to determine a baseline fetal heart rate. This is important in assessing the well-being of the fetus during labor, especially in the presence of genital herpes lesions. Monitoring the fetal heart rate helps in detecting any signs of distress or compromise due to maternal infection. A: Asking about the patient's last intake is important but not the immediate priority when managing a patient with active genital herpes lesions in labor. B: Taking a culture of the lesions might be helpful but not the immediate action needed in this situation. C: Asking about unprotected sex is relevant but not as critical as monitoring the fetal well-being during labor in this scenario. Overall, the most critical action is to monitor the fetal heart rate for any signs of distress related to the maternal herpes infection.
Question 9 of 9
When administering a patients eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal?
Correct Answer: C
Rationale: The correct answer is C: Occlude the puncta after applying the medication. By occluding the puncta after applying the eye drops, the nurse can prevent the medication from draining into the nasolacrimal duct and being absorbed systemically. This is important to ensure that the medication remains in the eye and exerts its intended local effect. Choice A (Ensure that the patient is well hydrated at all times) is incorrect because hydration status does not directly prevent absorption through the nasolacrimal duct. Choice B (Encourage self-administration of eye drops) is incorrect as the method of administration does not prevent absorption through the nasolacrimal duct. Choice D (Position the patient supine before administering eye drops) is incorrect as it does not address the specific issue of preventing absorption through the nasolacrimal duct.