ATI RN
foundation of nursing practice questions Questions
Question 1 of 9
A middle-aged female patient has been offered testing for HIV/AIDS upon admission to the hospital for an unrelated health problem. The nurse observes that the patient is visibly surprised and embarrassed by this offer. How should the nurse best respond?
Correct Answer: B
Rationale: Option B is the best response for the nurse to provide in this situation. By stating that the testing is offered to every adolescent and adult regardless of lifestyle, appearance, or history, the nurse conveys that HIV testing is a standard practice and not targeting the patient specifically. This can help reduce the patient's feeling of embarrassment or stigma associated with the offer of testing. It also emphasizes the importance of universal screening for HIV to promote early detection and treatment, regardless of risk factors or demographics. This response helps maintain the patient's dignity and encourages them to consider the testing in a non-judgmental way.
Question 2 of 9
A nurse is evaluating a nursing assistive personnel’s(NAP) care for a patient with an indwelling catheter. Which action by the NAP will cause the nurse to intervene?
Correct Answer: C
Rationale: Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. A key intervention to prevent catheter-associated urinary tract infections is prevention of urine back flow from the tubing and bag into the bladder. All the other actions are correct procedures and do not require immediate follow-up. The drainage bag should be emptied when it is half full to prevent tension and pulling on the catheter, which could result in trauma to the urethra and increase the risk for urinary tract infections. Urine specimens are traditionally obtained by temporarily kinking the tubing, while securing the catheter tubing to the patient’s thigh prevents catheter dislodgment and tissue injury.
Question 3 of 9
A patients rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this patients care, the nurse should identify what primary aim?
Correct Answer: B
Rationale: The primary aim when transitioning a patient with rapid cancer metastases from active treatment to palliative care is to prevent and relieve suffering. Palliative care focuses on enhancing quality of life, managing symptoms, and addressing physical, emotional, and spiritual needs. By prioritizing the prevention and relief of suffering, healthcare providers can work towards improving the patient's comfort and overall well-being during this difficult time. This approach aligns with the goals of palliative care, which aim to provide holistic support and care for patients facing serious illnesses like cancer.
Question 4 of 9
The nurse educator is discussing neoplasms with a group of recent graduates. The educator explains that he effects of neoplasms are caused by the compression and infiltration of normal tissue. The physiologic changes that result can cause what pathophysiologic events? Select all that apply.
Correct Answer: A
Rationale: Neoplasms can cause pathophysiologic events such as intracranial hemorrhage and increased intracranial pressure (ICP) due to expansion of the mass within the confined space of the skull. Intracranial hemorrhage can occur as the neoplasm damages blood vessels in the brain or causes them to become more fragile. Increased ICP can result from the growing mass causing compression of surrounding structures and obstructing the flow of cerebrospinal fluid, leading to symptoms such as headaches, nausea, vomiting, and changes in mental status.
Question 5 of 9
A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurses best response?
Correct Answer: C
Rationale: The nurse's best response is option C - "AIDS isn't transmitted by casual contact." This response is accurate and provides the necessary information to address the friend's concern. It is important to educate the friend that HIV/AIDS is not transmitted through casual contact such as visiting a patient in the hospital. By stating this fact clearly, the nurse can help alleviate any unfounded fears or misconceptions the friend may have about contracting HIV while visiting the patient. This response promotes understanding and helps reduce stigma associated with HIV/AIDS, while also emphasizing the importance of accurate information in preventing the spread of the virus.
Question 6 of 9
A patient is in the primary infection stage of HIV. What is true of this patients current health status?
Correct Answer: B
Rationale: During the primary infection stage of HIV, the patient is newly infected with the virus. At this stage, the patient's immune system has not yet produced HIV-specific antibodies, making it difficult to detect HIV infection using standard antibody tests. Instead, the virus can be detected by testing for the presence of HIV RNA or p24 antigen. The primary infection stage is characterized by a high level of viral replication and rapid spread of the virus throughout the body. In this early stage, the patient may experience flu-like symptoms such as fever, sore throat, muscle aches, and swollen lymph nodes. The absence of HIV-specific antibodies means that the patient is highly infectious and can easily transmit the virus to others. As the infection progresses, the patient will eventually develop HIV-specific antibodies, which can be detected through antibody tests.
Question 7 of 9
A nurse is providing care for a patient who has recently been admitted to the postsurgical unit from PACU following a transuretheral resection of the prostate. The nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order to assess for this risk, the nurse should prioritize what action?
Correct Answer: A
Rationale: The nurse should prioritize closely monitoring the input and output of the bladder irrigation system to assess for the risk of imbalanced fluid volume in a patient following a transuretheral resection of the prostate. Bladder irrigation is a common postoperative procedure used to prevent blood clots and help with healing. Monitoring the input and output of the bladder irrigation system is crucial in assessing the patient's fluid balance. Changes in the output may indicate bleeding or retention, which can lead to imbalanced fluid volume. By closely monitoring the bladder irrigation system, the nurse can promptly identify any issues and intervene accordingly to prevent further complications. Monitoring the patient's level of consciousness, skin turgor, and scanning for bladder retention are important assessments, but for this specific situation, monitoring the bladder irrigation system is the priority to assess for imbalanced fluid volume.
Question 8 of 9
A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered?
Correct Answer: D
Rationale: Recurrent episodes of acute otitis media (AOM) can cause fluid accumulation in the middle ear, leading to hearing loss and increased risk of further infections. Insertion of a ventilation tube, also known as a tympanostomy tube, is a common intervention for children with recurrent AOM. This procedure involves placing a tiny tube through the eardrum to allow ventilation and drainage of fluid from the middle ear. Ventilation tubes help equalize pressure, prevent fluid buildup, and reduce the frequency of ear infections. It can improve hearing and decrease the likelihood of future episodes of AOM. Ossiculoplasty, insertion of a cochlear implant, and stapedectomy are not indicated for recurrent AOM.
Question 9 of 9
The nurse in the ED is caring for a 4 year-old brought in by his parents who state that the child will not stop crying and pulling at his ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis?
Correct Answer: A
Rationale: External otitis, also known as swimmer's ear, is an infection of the outer ear canal. It is often characterized by aural tenderness, which means that the ear is sensitive to touch and can be painful, especially when pressure is applied to the area. This tenderness is a hallmark symptom of external otitis and helps differentiate it from other ear conditions. Other common symptoms of external otitis include ear pain, itchiness, redness, and swelling of the ear canal. External otitis is usually not accompanied by a high fever, and it is not typically related to an upper respiratory infection. Using cotton-tipped applicators to clean the ear can actually increase the risk of developing external otitis by disrupting the natural protective barrier of the ear canal.