ATI RN
foundation of nursing questions Questions
Question 1 of 9
A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
Correct Answer: B
Rationale: The correct answer is B: Tachypnea and restlessness. This observation takes immediate priority as it indicates potential respiratory distress, a common complication of pneumonia in HIV patients. Tachypnea can be a sign of hypoxia, while restlessness may indicate increased work of breathing. Prompt intervention is crucial to prevent respiratory failure. Choice A: Oral temperature of 100F is not an immediate priority as it is within normal range and may not directly impact the patient's immediate condition. Choice C: Frequent loose stools may suggest gastrointestinal issues but are not as urgent as respiratory distress in this scenario. Choice D: Weight loss of 1 pound since yesterday, while relevant in monitoring the patient's condition, does not require immediate intervention compared to respiratory distress.
Question 2 of 9
What should the nurse recognize as evidence that the patient is recovering from preeclampsia?
Correct Answer: C
Rationale: Step 1: Increased urine output indicates improved kidney function, a key indicator of recovery from preeclampsia. Step 2: Adequate urine output helps regulate blood pressure and reduce swelling. Step 3: Consistent urine output >100 mL/hour signifies the kidneys are functioning properly. Step 4: Therefore, C is the correct answer as it directly reflects recovery progress from preeclampsia. Summary: A, B, and D are incorrect as they do not directly correlate with kidney function or recovery from preeclampsia.
Question 3 of 9
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage?
Correct Answer: A
Rationale: The correct answer is A: Rinsing the ears with normal saline after swimming. This is because rinsing with normal saline helps to remove excess moisture and debris, preventing bacterial growth that can lead to otitis externa. Avoiding loud noises (B) is important for overall ear health but does not specifically prevent otitis externa. Instilling antibiotic ointments regularly (C) is not recommended as it can disrupt the ear's natural flora. Avoiding cotton swabs (D) is important to prevent injury but does not directly prevent otitis externa.
Question 4 of 9
The nurse is reviewing the instructions given to a patient at 24 weeks’ gestation for a glucose challenge test (GCT). The nurse determines that the patient understands the teaching when she makes which statement?
Correct Answer: C
Rationale: The correct answer is C: “I will have blood drawn at 1 hour after I drink the glucose solution.” This statement demonstrates understanding of the GCT procedure. The glucose challenge test involves drinking a sugary solution, followed by blood drawn 1 hour later to measure blood glucose levels. This timing is crucial for assessing the body's ability to metabolize glucose, which helps in diagnosing gestational diabetes. Explanation of why the other choices are incorrect: A: “I have to fast the night before the test.” - This is incorrect as fasting is not required for the GCT. B: “I will drink a sugary solution containing 100 g of glucose.” - This is incorrect as the GCT typically involves drinking a solution with a standardized amount of glucose, usually 50 g, not 100 g. D: “I should keep track of my baby’s movements between now and the test.” - This is unrelated to the GCT procedure and does not demonstrate understanding of the
Question 5 of 9
A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T- lymphocyte cell count drops below what threshold?
Correct Answer: B
Rationale: The correct answer is B (200 cells/mm3 of blood) because a patient with HIV is considered to have AIDS when their CD4+ T-lymphocyte cell count drops below 200 cells/mm3. This threshold signifies a significant decrease in the immune system's ability to fight off infections and indicates progression to AIDS. Choice A (75 cells/mm3 of blood) is incorrect because this level is extremely low and would indicate severe immunosuppression, likely leading to AIDS much earlier than anticipated. Choice C (325 cells/mm3 of blood) and D (450 cells/mm3 of blood) are also incorrect as these levels are within the normal range or slightly lower, which would not meet the criteria for a diagnosis of AIDS.
Question 6 of 9
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement. Summary of Incorrect Choices: A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach. B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage. D: Measuring from the tip of the nose to the earlobe to
Question 7 of 9
What is the priority nursing intervention for the patient who has had an incomplete abortion?
Correct Answer: C
Rationale: The correct answer is C because the priority nursing intervention for a patient with incomplete abortion is to ensure adequate fluid replacement to prevent hypovolemic shock due to potential blood loss. Inserting an IV line allows for immediate administration of fluids and medications if necessary. Choice A (Methylergonovine) is used to manage postpartum hemorrhage, not incomplete abortion. Choice B (Preoperative teaching) and choice D (Positioning) are important but not the priority in this situation.
Question 8 of 9
A nurse is providing care to a culturally diversepopulation. Which action indicates the nurse is successful in the role of providing culturally congruent care?
Correct Answer: A
Rationale: The correct answer is A because providing care that fits the patient's valued life patterns and set of meanings demonstrates cultural congruence. This approach acknowledges and respects the patient's cultural background, beliefs, and preferences. It promotes patient-centered care and enhances communication and trust between the nurse and the patient. Choice B is incorrect because care based on predetermined criteria may not align with the patient's individual cultural needs. Choice C is incorrect as it does not prioritize the patient's values and preferences. Choice D is incorrect because providing care based solely on the values of the professional health care system may not consider the cultural diversity of the patient population.
Question 9 of 9
A nurse is using core measures to reduce healthdisparities. Which group should the nurse focus on to cause themost improvement in core measures?
Correct Answer: B
Rationale: The correct answer is B: Poor people. Focusing on poor people is likely to cause the most improvement in core measures because individuals living in poverty often face multiple barriers to accessing healthcare and have higher rates of chronic conditions. By targeting this group, the nurse can address social determinants of health, improve healthcare access, and address disparities in healthcare outcomes. Other choices (A, C, D) are not as impactful as poverty is a significant factor influencing health disparities.