ATI RN
foundations of nursing practice questions Questions
Question 1 of 5
A hospital nurse has experienced percutaneous exposure to an HIV-positive patients blood as a result of a needlestick injury. The nurse has informed the supervisor and identified the patient. What action should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Report to the emergency department or employee health department. 1. Immediate action is crucial after exposure to HIV-positive blood. 2. Reporting to the emergency department or employee health department ensures prompt evaluation and appropriate management. 3. The supervisor should also be informed to initiate the necessary protocols. 4. The other choices are incorrect: - A: Chlorhexidine may not be sufficient for post-exposure prophylaxis. - C: Hydrocolloid dressing is not appropriate for managing needlestick injuries. - D: Following up with the primary care provider may cause delays in receiving timely post-exposure prophylaxis.
Question 2 of 5
The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction?
Correct Answer: A
Rationale: The correct answer is A: Anaphylactic reaction after a bee sting. Type I hypersensitivity reactions involve an immediate response triggered by exposure to an allergen, leading to the release of histamine and other inflammatory mediators. In this case, a bee sting would introduce an allergen, causing a rapid and severe systemic reaction, known as anaphylaxis. B: Skin reaction resulting from adhesive tape is an example of a Type IV hypersensitivity reaction, mediated by T cells, not IgE antibodies as in Type I reactions. C: Myasthenia gravis is an autoimmune disorder involving antibodies attacking acetylcholine receptors, not a Type I hypersensitivity reaction. D: Rheumatoid arthritis is an autoimmune disorder involving immune complexes and inflammatory responses, not a Type I hypersensitivity reaction.
Question 3 of 5
A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will present with what alteration in laboratory values?
Correct Answer: A
Rationale: The correct answer is A: Increased eosinophils. Eosinophils are a type of white blood cell involved in allergic reactions. During anaphylaxis, the body releases chemicals that stimulate the production and activation of eosinophils, leading to an increase in their count. This helps in the identification of an allergic reaction. Incorrect Choices: B: Increased neutrophils - Neutrophils are not specific to allergic reactions and are typically increased in bacterial infections. C: Increased serum albumin - Serum albumin levels are not directly affected by allergic reactions. D: Decreased blood glucose - Hypoglycemia is not a typical manifestation of an allergic reaction.
Question 4 of 5
The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the patients care plan?
Correct Answer: D
Rationale: The correct answer is D: Risk for Self-Care Deficit Related to Skin Lesions. Patients with atopic dermatitis may experience difficulty performing self-care tasks due to pain, itching, and limitations in hand mobility caused by skin lesions. This diagnosis addresses the potential challenges the patient may face in maintaining personal hygiene and managing their skin condition. Explanation for why other choices are incorrect: A: Risk for Disturbed Body Image Related to Skin Lesions - While atopic dermatitis may impact body image, the priority in this case is the patient's ability to perform self-care. B: Risk for Disuse Syndrome Related to Dermatitis - Disuse syndrome is not typically associated with atopic dermatitis. C: Risk for Ineffective Role Performance Related to Dermatitis - This diagnosis focuses on the patient's ability to fulfill their roles, which may not be directly impacted by atopic dermatitis.
Question 5 of 5
A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, When I was young I used to take antihistamines, but they always put me to sleep. How should the nurse best respond?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. The newer antihistamines, such as second-generation antihistamines like loratadine or cetirizine, are designed to cause less sedation compared to older antihistamines like diphenhydramine. 2. These newer antihistamines have a lower affinity for crossing the blood-brain barrier, reducing the sedative effects. 3. Therefore, suggesting that the newer antihistamines are different and cause less sedation is the best response to address the patient's concerns. Summary of Incorrect Choices: A. While some newer antihistamines may be combined with decongestants to offset drowsiness, this is not a consistent feature of all newer antihistamines. B. Developing tolerance to sedation after a few months is not a common or reliable response to antihistamines. D. Taking antihistamines at bedtime may help with sedation, but it does not address