ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having trouble breathing. What should the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Anaphylaxis due to a latex allergy. Anaphylaxis is a severe allergic reaction that can be triggered by exposure to latex products such as gloves in the operating room. The symptoms of swelling of the eyes and difficulty breathing are classic signs of anaphylaxis. Rationale: 1. Swelling of the eyes and difficulty breathing are hallmark symptoms of anaphylaxis. 2. Latex is a common allergen that can cause severe allergic reactions like anaphylaxis. 3. The student's symptoms are occurring shortly after entering the operating room, suggesting an acute allergic reaction. 4. The other choices (A, B, D) do not align with the symptoms presented and are less likely in this scenario.
Question 2 of 9
A man comes to the clinic complaining that he is having difficulty obtaining an erection. When reviewing the patients history, what might the nurse note that contributes to erectile dysfunction?
Correct Answer: B
Rationale: The correct answer is B: The patient has a history of hypertension. Hypertension is a risk factor for erectile dysfunction as it can lead to reduced blood flow to the penis, impacting the ability to achieve and maintain an erection. High blood pressure can damage blood vessels and affect the circulation necessary for an erection. Other choices are less likely to directly contribute to erectile dysfunction. A: UTI treatment is not typically associated with erectile dysfunction. C: Age alone is not a direct cause of erectile dysfunction, although it can increase the risk. D: While a sedentary lifestyle can impact overall health, it is less likely to directly cause erectile dysfunction compared to hypertension.
Question 3 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 4 of 9
A nurse is preparing to document a patient whohas chest pain. Which information is critical for the nurse to include?
Correct Answer: D
Rationale: The correct answer is D because documenting the patient's pain intensity using a pain scale (8 out of 10) is crucial for assessing the severity of the chest pain. This information helps in determining the appropriate intervention and monitoring the effectiveness of treatment. Choice A is irrelevant as it does not provide any useful information about the patient's condition. Choice B is important for neurological assessment but not specifically related to chest pain. Choice C is not as critical as knowing the current pain level.
Question 5 of 9
Which finding would indicate concealed hemorrhage in abruptio placentae?
Correct Answer: B
Rationale: The correct answer is B: Hard boardlike abdomen. In abruptio placentae, concealed hemorrhage can lead to blood accumulating behind the placenta, causing the uterus to become tense and rigid, resulting in a hard boardlike abdomen. This finding indicates significant internal bleeding and requires immediate medical attention. Rationale: A: Bradycardia is a slow heart rate and is not typically associated with concealed hemorrhage in abruptio placentae. C: Decrease in fundal height may indicate intrauterine growth restriction, not specifically concealed hemorrhage. D: Decrease in abdominal pain is not a typical indicator of concealed hemorrhage; in fact, pain may increase due to the increased pressure in the uterus from the bleeding.
Question 6 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 7 of 9
The nurse is caring for patients with ostomies.In which ostomy location will the nurse expect very liquid stool to be present?
Correct Answer: C
Rationale: The correct answer is C: Ascending. Stool consistency varies based on the location of the ostomy. The ascending colon is responsible for absorbing water from stool, so an ostomy in this location will have very liquid stool. Sigmoid, transverse, and descending colons are responsible for further solidifying stool, so ostomies in those locations would not typically have very liquid stool.
Question 8 of 9
A patient who was pregnant had a spontaneous abortion at approximately 4 weeks’ gestation. At the time of the miscarriage, it was thought that all products of conception were expelled. Two weeks later, the patient presents at the clinic office complaining of “crampy” abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/minute (bpm), and respirations, 20 breaths per minute. Based on this assessment data, what does the nurse anticipate as a clinical diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Uterine infection. The patient's symptoms of crampy abdominal pain, scant serosanguineous vaginal drainage with odor, negative pregnancy test, and vital signs indicating fever, low blood pressure, and irregular pulse suggest an infection. The history of recent miscarriage raises suspicion for retained products of conception leading to infection. Ectopic pregnancy (choice A) would present with different symptoms such as abdominal pain, vaginal bleeding, and positive pregnancy test. Gestational trophoblastic disease (choice C) typically presents with abnormal vaginal bleeding and high levels of hCG. Endometriosis (choice D) is a chronic condition and not related to the acute symptoms described. In summary, the clinical presentation aligns with uterine infection given the patient's history, symptoms, and vital signs.
Question 9 of 9
Fraternal twins are delivered by your Rh-negative patient. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the
Correct Answer: C
Rationale: The correct answer is C: indirect Coombs test of the mother. This test is crucial to determine if the mother has developed antibodies against the Rh-positive blood of twin A, which could lead to hemolytic disease of the newborn in future pregnancies. A direct Coombs test of twin A or twin B is not relevant in this scenario as it does not provide information about the mother's antibody status. Transcutaneous bilirubin levels are used to monitor jaundice in newborns and not related to Rh incompatibility. In summary, the indirect Coombs test of the mother is the most relevant test to assess the risk of hemolytic disease in future pregnancies.