ATI RN
test bank foundations of nursing Questions
Question 1 of 9
A 35-year-old mother of three young children has been diagnosed with stage II breast cancer. After discussing treatment options with her physician, the woman goes home to talk to her husband, later calling the nurse for clarification of some points. The patient tells the nurse that the physician has recommended breast conservation surgery followed by radiation. The patients husband has done some online research and is asking why his wife does not have a modified radical mastectomy to be sure all the cancer is gone. What would be the nurses best response?
Correct Answer: D
Rationale: The correct answer is D: According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy. 1. Breast conservation surgery followed by radiation is a standard treatment option for early-stage breast cancer. 2. Studies have shown that breast conservation surgery combined with radiation therapy is equally effective in terms of long-term survival rates compared to mastectomy. 3. Current guidelines recommend considering breast conservation surgery as a viable option for patients with early-stage breast cancer. 4. Modified radical mastectomy is not necessarily needed to ensure complete removal of cancer, as breast conservation surgery followed by radiation can achieve the same goal. 5. Therefore, the nurse should reassure the patient's husband that the recommended treatment plan is based on current guidelines and is as effective as a modified radical mastectomy.
Question 2 of 9
A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child?
Correct Answer: A
Rationale: Step 1: Handwashing is crucial in preventing the spread of viral conjunctivitis, which is highly contagious. Step 2: Children often touch their eyes and then surfaces, aiding in disease transmission. Step 3: Educating parents and the child on proper hand hygiene can help contain the infection. Step 4: Antibiotics are not effective against viral infections, so compliance is not necessary. Step 5: Complications like meningitis and septicemia are extremely rare with viral conjunctivitis. Step 6: Surgery is not indicated for viral conjunctivitis, as it is a self-limiting condition.
Question 3 of 9
Rh incompatibility can occur if the patient is Rh-negative and the
Correct Answer: B
Rationale: The correct answer is B because Rh incompatibility occurs when an Rh-negative mother carries an Rh-positive fetus. If fetal blood enters the mother's circulation during pregnancy or childbirth, the mother's immune system can produce antibodies against Rh-positive red blood cells, leading to potential harm to future pregnancies. Choices A, C, and D are incorrect because Rh incompatibility does not occur when the fetus is Rh-negative, the father is Rh-positive, or both the father and fetus are Rh-negative.
Question 4 of 9
A nurse is planning the care of a patient with AIDS who is admitted to the unit withPneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?
Correct Answer: A
Rationale: The correct answer is A: Ineffective Airway Clearance. In a patient with AIDS and PCP, maintaining clear airways is crucial to prevent respiratory distress and hypoxia. Pneumocystis pneumonia can cause thick secretions and mucus plugging, leading to difficulty breathing. Ensuring effective airway clearance is a priority to optimize oxygenation and prevent respiratory complications. Impaired oral mucous membranes (B) and imbalanced nutrition (C) are important considerations but not as immediate as airway clearance. Activity intolerance (D) may be a concern for the patient but ensuring adequate oxygenation takes precedence.
Question 5 of 9
A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient’s magnesium level is 6 mg/dL. What is the nurse’s priority action?
Correct Answer: A
Rationale: The correct answer is A: Stop the infusion of magnesium. A magnesium level of 6 mg/dL is above the therapeutic range (4-7 mg/dL) for preeclamptic patients receiving magnesium sulfate. Continuing the infusion can lead to magnesium toxicity, causing respiratory depression, cardiac arrest, and neuromuscular blockade. Stopping the infusion is crucial to prevent further complications. Assessing the patient's respiratory rate (B) and deep tendon reflexes (C) are important, but stopping the infusion takes priority to prevent harm. Notifying the health care provider (D) is important but may delay immediate action to address the high magnesium level.
Question 6 of 9
A patient diagnosed with cervical cancer will soon begin a round of radiation therapy. When planning the patients subsequent care, the nurse should prioritize actions with what goal?
Correct Answer: C
Rationale: The correct answer is C: Protecting the safety of the patient, family, and staff. This is the priority when planning care for a patient undergoing radiation therapy due to the potential risks of radiation exposure to others. Ensuring safety involves implementing proper radiation safety protocols, educating the patient and family on safety measures, and providing a safe environment for all. Choices A, B, and D are incorrect. Preventing hemorrhage is important but not the top priority during radiation therapy. Ensuring the patient understands the treatment's purpose is essential but not the immediate priority. Adherence to dietary restrictions is important for overall health but is not the primary focus when prioritizing actions for radiation therapy.
Question 7 of 9
The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patients immediate family members to undergo clinical examinations how often?
Correct Answer: B
Rationale: The correct answer is B: At least once every 2 years. Glaucoma has a familial tendency, meaning it can run in families. Regular eye exams are crucial for early detection and treatment. Having family members undergo clinical examinations every 2 years allows for timely identification of any potential signs of glaucoma. Monthly exams (A) would be too frequent and unnecessary. Exams every 5 years (C) or 10 years (D) are too infrequent and may miss early signs of the disease. Regular biennial exams strike a balance between early detection and practicality.
Question 8 of 9
A medical nurse is providing palliative care to a patient with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurses care?
Correct Answer: A
Rationale: The correct answer is A: To improve the patients and familys quality of life. In palliative care for end-stage COPD, the primary goal is to enhance quality of life by managing symptoms, providing emotional support, and ensuring comfort. Choice B is incorrect as palliative care focuses on comfort rather than aggressive treatments. Choice C is incorrect because palliative care encompasses not only physical but also emotional, social, and spiritual support. Choice D is incorrect as the goal is to provide holistic care rather than separate plans for each discipline. Ultimately, the primary focus of palliative care in this scenario is to improve the overall quality of life for the patient and their family.
Question 9 of 9
A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education?
Correct Answer: B
Rationale: The correct answer is B: Compensating for vision loss for the next several weeks. This is the priority subject for discharge education because vision loss is a common outcome post vitreoretinal procedure. The patient needs to understand how to adapt to this temporary impairment, such as using assistive devices and modifying their environment. A: Risk factors for postoperative CMV is not the priority as it is not a common concern in this situation. C: Non-pharmacologic pain management is important but not the priority compared to vision loss. D: Signs and symptoms of increased intraocular pressure are important but not as crucial as managing vision loss.