ATI RN
foundations of nursing test bank Questions
Question 1 of 9
A laboratory finding indicatiNveU oRf SDIICN iGs oTnBe .thCatO sMhows
Correct Answer: A
Rationale: The correct answer is A: decreased fibrinogen. In disseminated intravascular coagulation (DIC), there is widespread activation of coagulation leading to consumption of clotting factors like fibrinogen, resulting in decreased levels. Platelets are usually decreased, not increased, in DIC. Hematocrit may be elevated due to hemoconcentration but not directly related to DIC. Thromboplastin time would be prolonged, not decreased, in DIC due to consumption of clotting factors.
Question 2 of 9
A patient is being discharged home after mastoid surgery. What topic should the nurse address in the patients discharge education?
Correct Answer: C
Rationale: Step 1: After mastoid surgery, patients may experience pain and dizziness, hence addressing the safe use of analgesics and antivertiginous agents is crucial for symptom management. Step 2: Analgesics help in managing post-operative pain, while antivertiginous agents help control dizziness, reducing the risk of falls. Step 3: Educating the patient on safe use ensures proper pain and symptom management, preventing complications. Step 4: Other choices are incorrect as they do not directly address immediate post-operative care needs such as pain and dizziness management.
Question 3 of 9
Which findings should the nurse follow up on afterremoval of a catheter from a patient? (Select allthat apply.)
Correct Answer: B
Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection. A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal. C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem. D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.
Question 4 of 9
The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?
Correct Answer: D
Rationale: The correct answer is D: Mobility. A malignant breast tumor typically lacks mobility due to its fixed attachment to surrounding tissues. This characteristic is concerning for malignancy as it suggests invasive growth. Incorrect answers: A: Nontenderness - Tenderness does not reliably indicate malignancy or benignancy. B: A size of 5 mm - Tumor size alone does not determine malignancy. C: Softness and a regular shape - Malignant tumors are often firm and irregular in shape.
Question 5 of 9
A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient?
Correct Answer: B
Rationale: The correct answer is B because hearing loss and tinnitus caused by aspirin are typically irreversible. Aspirin is known to cause ototoxicity, which can lead to permanent damage to the auditory system. The nurse should inform the patient that the hearing loss and tinnitus may not improve even after discontinuing aspirin. Choice A is incorrect because hearing loss caused by aspirin is usually permanent. Choice C is incorrect because aspirin is a known cause of tinnitus and hearing loss. Choice D is incorrect because tolerance to aspirin does not prevent or reverse ototoxic effects like tinnitus and hearing loss.
Question 6 of 9
A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Application of topical antibiotic ointment. After enucleation, there is a risk of infection at the surgical site. By applying topical antibiotic ointment as directed, the patient can help prevent infection and promote healing. This is a crucial aspect of postoperative care. B: Maintenance of a supine position for the first 48 hours postoperative is incorrect. Patients may be advised to avoid lying flat on their back to prevent complications such as pressure on the surgical site. C: Fluid restriction to prevent orbital edema is incorrect. Fluid restriction is not typically necessary post-enucleation unless specifically advised by the healthcare provider. D: Administration of loop diuretics to prevent orbital edema is incorrect. Loop diuretics are not typically used for preventing orbital edema post-enucleation. E: Use of an ocular pressure dressing is incorrect. While dressings may be used postoperatively, the application of topical antibiotic ointment is more
Question 7 of 9
The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa?
Correct Answer: C
Rationale: The correct answer is C because African-American ethnicity and previous cesarean birth are established risk factors for placenta previa due to the potential for scarring and abnormal placental implantation. Male fetus does not influence the risk. Asian-American ethnicity and previous preterm birth are not significant risk factors. European-American ethnicity and previous spontaneous abortion are also not associated with an increased risk of placenta previa.
Question 8 of 9
A patient has just been told that her illness is terminal. The patient tearfully states, I cant believe I am going to die. Why me? What is your best response?
Correct Answer: C
Rationale: The correct answer is C: "This must be very difficult for you." This response acknowledges the patient's emotional state and shows empathy without making assumptions or dismissing their feelings. It validates the patient's emotions and opens up the opportunity for further discussion or support. Rationale: 1. A: "I know how you are feeling" assumes the tutor knows the exact emotions of the patient, which can come off as insincere or dismissive. 2. B: "You have lived a long life" does not address the patient's emotional distress or provide comfort in the face of a terminal illness. 3. D: "Life can be so unfair" does not directly address the patient's feelings and may come off as generic or cliché.
Question 9 of 9
A patient with a genital herpes exacerbation has a nursing diagnosis of acute pain related to the genital lesions. What nursing intervention best addresses this diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Keep the lesions clean and dry. This intervention helps prevent infection and promotes healing. Cleaning the lesions reduces the risk of secondary infections and discomfort. Keeping the area dry can also help alleviate pain and discomfort associated with moisture. Covering with a topical antibiotic (A) may not address pain directly and could potentially irritate the lesions. Applying a topical NSAID (C) may provide some pain relief but does not address the primary need to keep the lesions clean and dry. Remaining on bed rest (D) is not necessary for managing acute pain related to genital lesions.