ATI RN
foundation of nursing questions Questions
Question 1 of 9
A child has been transported to the emergency department (ED) after a severe allergic reaction. The ED nurse is evaluating the patients respiratory status. How should the nurse evaluate the patients respiratory status? Select all that apply.
Correct Answer: B
Rationale: Rationale: Assessing breath sounds is crucial in evaluating respiratory status as it helps identify any signs of airway obstruction or respiratory distress. This includes listening for wheezing, crackles, or diminished breath sounds. Lung function testing (A) may not be feasible in an acute emergency situation. Oxygen saturation (C) is important but does not provide a comprehensive assessment of respiratory status. Monitoring respiratory pattern (D) and assessing respiratory rate (E) are important but do not directly assess breath sounds, which are vital in identifying immediate respiratory issues.
Question 2 of 9
A placenta previa when the placental edge just reaches the internal os is called
Correct Answer: D
Rationale: The correct answer is D, marginal. Placenta previa is classified based on the proximity of the placental edge to the internal os. In a marginal placenta previa, the placental edge just reaches the internal os. This is a crucial distinction as it poses a higher risk for bleeding during labor. Total placenta previa covers the entire internal os, partial placenta previa partially covers the internal os, and low-lying placenta is when the placenta is close to but not covering the internal os. Therefore, D is correct as it accurately describes the specific position of the placenta edge in relation to the internal os in cases of marginal placenta previa.
Question 3 of 9
A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the patients preoperative teaching?
Correct Answer: B
Rationale: The correct answer is B: The patient is likely to experience resolution of conductive hearing loss after the procedure. This information is crucial to include in the preoperative teaching because it directly addresses the patient's expected outcome, providing reassurance and setting appropriate expectations. Stapedectomy with prosthesis insertion is a well-established treatment for otosclerosis-related conductive hearing loss. Choices A, C, and D are incorrect because they either provide misleading information (A, D) or are not directly relevant to the procedure or the patient's immediate postoperative experience (C). It is important to focus on accurate and relevant information to prepare the patient effectively for the upcoming surgery and its expected outcomes.
Question 4 of 9
When planning discharge teaching with a patient who has undergone a total mastectomy with axillary dissection, the nurse knows to instruct the patient that she should report what sign or symptom to the physician immediately?
Correct Answer: C
Rationale: The correct answer is C: Sudden cessation of output from the drainage device. This is crucial because it can indicate a potential complication like a blocked drain or infection, requiring immediate medical attention to prevent further issues. Other choices like fatigue (A) are common after surgery but not urgent. Temperature elevation (B) may indicate infection but is not as critical as sudden cessation of drainage. Gradual decline in output (D) is expected as the drainage decreases over time, so it doesn't require immediate reporting.
Question 5 of 9
The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is themostlikely cause of the diarrhea?
Correct Answer: C
Rationale: The correct answer is C: Formula intolerance. When a patient develops diarrhea shortly after starting enteral feeding, formula intolerance is the most likely cause. This can occur due to the patient's inability to tolerate certain ingredients in the formula, leading to gastrointestinal upset. Antibiotics (choice A) and Clostridium difficile (choice B) typically take longer to cause diarrhea. Bacterial contamination (choice D) would usually result in more severe symptoms beyond just diarrhea. In this scenario, formula intolerance is the most logical explanation for the immediate onset of diarrhea after starting enteral feeding.
Question 6 of 9
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
Correct Answer: B
Rationale: The correct answer is B: Thigh. When administering epinephrine during an anaphylactic reaction, the thigh is the recommended site due to its large muscle mass and quick absorption rate. Steps: 1. Remove safety cap. 2. Firmly push the auto-injector against the thigh until it clicks. 3. Hold in place for a few seconds. 4. Seek medical help immediately. Rationale for incorrect choices: A: Forearm - Not recommended due to smaller muscle mass and slower absorption. C: Deltoid muscle - Not preferred as it may not provide as rapid absorption as the thigh. D: Abdomen - Not ideal due to potential fat layers that could affect absorption speed.
Question 7 of 9
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
Correct Answer: B
Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention. Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B. Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B. Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.
Question 8 of 9
A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The glass had to be surgically removed and the patient is about to be discharged home. The patient asks the nurse for a topical anesthetic for the pain in his eye. What should the nurse respond?
Correct Answer: A
Rationale: The correct answer is A. Overuse of topical anesthetics can soften the cornea and damage the eye. Topical anesthetics numb the eye, masking pain and potentially leading to overuse. This can prevent the patient from recognizing potential issues like infection or further injury. Additionally, prolonged use can interfere with the cornea's ability to heal properly. Choices B, C, and D are incorrect because they do not address the specific risks associated with using topical anesthetics in the eye. Option B focuses on peripheral vision loss, which is not a direct consequence of using topical anesthetics. Choice C mentions controlled substances, which is not relevant to the situation. Option D acknowledges the patient's request but does not educate the patient on the potential harm of overusing topical anesthetics.
Question 9 of 9
A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Decreased skin turgor. Diarrhea leads to fluid loss, causing dehydration and decreased skin turgor. This indicates the patient's hydration status. A: Distended abdomen is more common in conditions like bowel obstruction, not necessarily in diarrhea. C: Increased energy levels are unlikely due to the patient's weakened state from dehydration. D: Elevated blood pressure is not typically associated with dehydration.