ATI RN
test bank foundations of nursing Questions
Question 1 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 2 of 9
The nurse is caring for a patient withClostridiumdifficile. Which nursing actions will have thegreatest impact in preventing the spread of the bacteria?
Correct Answer: D
Rationale: Correct Answer: D - Proper hand hygiene techniques Rationale: 1. Clostridium difficile is mainly spread through contact with contaminated surfaces. 2. Proper hand hygiene is the most effective way to prevent the spread of bacteria. 3. Hand hygiene removes bacteria from hands, reducing the risk of transmission. 4. Appropriate disposal (A) is important but doesn't directly prevent spread. Monthly in-services (B) and mandatory cultures (C) are not as effective as hand hygiene in preventing transmission.
Question 3 of 9
A patient has just been diagnosed with Parkinsons disease and the nurse is planning the patients subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patients family?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. Patients with Parkinson's disease are at risk for falls due to symptoms like tremors and impaired balance. Educating the family about fall prevention measures is crucial. Choice A, Risk for infection, is not directly related to Parkinson's disease. Choice B, Impaired spontaneous ventilation, is not a common concern in Parkinson's disease. Choice C, Unilateral neglect, is more commonly seen in conditions like stroke, not Parkinson's disease. Therefore, the most appropriate nursing diagnosis for the patient with Parkinson's disease is addressing the risk for injury to prevent falls.
Question 4 of 9
A patient was prescribed an oral antibiotic for the treatment of sinusitis. The patient has now stopped, stating she developed a rash shortly after taking the first dose of the drug. What is the nurses most appropriate response?
Correct Answer: B
Rationale: The correct answer is B: Refer the woman to her primary care provider to have the medication changed. Rationale: 1. Rash after taking the first dose of an antibiotic suggests a possible allergic reaction. 2. Allergic reactions can range from mild to severe, including anaphylaxis. 3. It is crucial to discontinue the suspected medication to prevent worsening of the reaction. 4. Referring the patient to their primary care provider ensures proper evaluation and management. 5. Changing the medication is necessary to avoid potential harm from continued exposure. Summary: A: Continuing the medication can worsen the allergic reaction and is not recommended. C: Going to the emergency department may be excessive at this point for a mild rash. D: Taking an antihistamine does not address the underlying issue of an allergic reaction.
Question 5 of 9
A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Current medication regimen. In the admission assessment of a patient with AIDS, it is crucial to assess the patient's current medication regimen to ensure proper management of the condition. This includes antiretroviral therapy, prophylactic medications, and any other medications the patient may be taking to manage comorbidities. Understanding the medications the patient is currently taking allows the nurse to assess for potential drug interactions, side effects, and adherence to the treatment plan. This information is essential for providing safe and effective care for the patient. Choice B: Identification of patients support system is important but not a specific component of the comprehensive assessment for a patient with AIDS. Choice C: Immune system function is a relevant aspect in a patient with AIDS, but it is not typically assessed in the admission assessment as it requires specialized testing. Choice D: Genetic risk factors for HIV are not typically assessed in the admission assessment of a patient with AIDS as the focus is on the current condition and management
Question 6 of 9
Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely cause this abnormality?
Correct Answer: A
Rationale: The correct answer is A: Rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, which includes bilateral cataracts as a characteristic feature. Rubella virus can cross the placenta and affect the developing fetus. Cytomegalovirus (CMV) can also cause congenital cataracts, but rubella is more commonly associated with this abnormality. Syphilis can cause other congenital abnormalities but not bilateral cataracts. HIV does not typically lead to bilateral cataracts in newborns.
Question 7 of 9
The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively?
Correct Answer: B
Rationale: The correct answer is B. By asking the patient to demonstrate the instillation of medications, the nurse can directly assess the patient's ability to self-administer the medications safely and effectively. This method allows for a practical demonstration of skills, which is more reliable than relying solely on verbal descriptions or past experiences. Choices A, C, and D are incorrect because assessing for previous inability, describing the method, or evaluating functional status may not directly demonstrate the patient's competency in self-administering ocular medications.
Question 8 of 9
The home health nurse is performing a home visit for an oncology patient discharged 3 days ago after completing treatment for non-Hodgkin lymphoma. The nurses assessment should include examination for the signs and symptoms of what complication?
Correct Answer: A
Rationale: The correct answer is A: Tumor lysis syndrome (TLS). In this scenario, the oncology patient has completed treatment for non-Hodgkin lymphoma. TLS is a potential complication post-treatment due to the rapid breakdown of cancer cells, leading to release of intracellular contents like potassium, phosphorus, and uric acid into the bloodstream. This can result in electrolyte imbalances, renal failure, and cardiac arrhythmias. The nurse should assess for signs such as hyperkalemia, hyperphosphatemia, hypocalcemia, and elevated uric acid levels. Monitoring renal function and fluid status is crucial. Summary of other choices: B: Syndrome of inappropriate ADH (SIADH) is characterized by excessive release of antidiuretic hormone leading to water retention and dilutional hyponatremia. Not typically associated with post-treatment complications in oncology patients. C: Disseminated intravascular coagulation (DIC)
Question 9 of 9
The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Supporting the patients and family's values and choices. In this scenario, the nurse should prioritize respecting the patient's preference to receive care at home and involving the family in decision-making. This approach promotes patient autonomy, dignity, and quality of life. Choice A is incorrect as aggressively fighting the disease process may not align with the patient's wishes for comfort-focused care in hospice. Choice B is incorrect because moving the patient to a long-term care facility goes against the patient's preference to receive care at home. Choice C is not the priority as including the children in planning care is important but not as crucial as respecting the patient's wishes directly.