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
The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision?
Correct Answer: C
Rationale: The correct answer is C because reviewing current medications with a pharmacist is crucial in understanding potential threats to vision. Some medications can have side effects that impact eye health. This proactive approach shows an understanding of how medication can affect vision. Choice A is incorrect because while avoiding direct sunlight is important for eye health, it does not address other potential threats. Choice B is incorrect because regular exercise, while beneficial for overall health, does not directly relate to understanding threats to vision. Choice D is incorrect because monitoring blood pressure is important for cardiovascular health but does not specifically address threats to vision.
Question 3 of 9
The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?
Correct Answer: A
Rationale: The correct answer is A because measuring capillary blood glucose level is a task that can be safely delegated to nursing assistive personnel. This task is within their scope of practice and does not require specialized nursing knowledge. Nursing assistive personnel can perform this task accurately with proper training and supervision. Incorrect choices: B: Measuring nasoenteric tube for insertion requires specialized training and assessment skills that nursing assistive personnel may not possess. C: Measuring pH in gastrointestinal aspirate involves interpretation and clinical judgment that should be done by a licensed nurse. D: Measuring the patient's risk for aspiration involves critical thinking and assessment skills that are beyond the scope of nursing assistive personnel.
Question 4 of 9
The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient?
Correct Answer: A
Rationale: The correct answer is A because providing instructions in simple, clear terms is crucial when communicating with a blind patient. This method allows the patient to understand information effectively without visual cues. Choice B is incorrect because a firm, loud voice may startle the patient. Choice C is incorrect as touching a patient without consent may be inappropriate. Choice D is incorrect because stating name and role without context may confuse the patient.
Question 5 of 9
A patient has returned to the post-surgical unit after vulvar surgery. What intervention should the nurse prioritize during the initial postoperative period?
Correct Answer: C
Rationale: The correct answer is C: Monitoring the integrity of the surgical site. This is the priority intervention as it ensures early detection of any complications like infection or bleeding. The nurse should assess for signs of infection, such as redness, swelling, or drainage, and monitor for any changes in the wound appearance. Placing the patient in high Fowler's position (A) may be beneficial for comfort but is not the priority. Administering sitz baths (B) may be helpful for comfort but should not be the priority over monitoring the surgical site. Avoiding analgesics (D) unless the pain is unbearable is not appropriate as pain management is essential for the patient's comfort and recovery.
Question 6 of 9
The nurse is teaching a health class about thegastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients?
Correct Answer: D
Rationale: The correct answer is D: Duodenum. The duodenum is the first part of the small intestine where most of the digestion and absorption of nutrients occurs. It receives partially digested food from the stomach and mixes it with bile and pancreatic enzymes to break down nutrients. The villi in the duodenum increase the surface area for absorption. The other choices (A: Ileum, B: Cecum, C: Stomach) are incorrect because the ileum and cecum are parts of the small intestine where some absorption occurs but not as much as in the duodenum. The stomach primarily digests food and does not absorb many nutrients.
Question 7 of 9
A nurse is planning the postoperative care of a patient who is scheduled for radical prostatectomy. What intraoperative position will place the patient at particular risk for the development of deep vein thrombosis postoperatively?
Correct Answer: D
Rationale: The correct answer is D: Lithotomy position. In lithotomy position, the patient's legs are elevated and positioned higher than the heart, which can lead to venous stasis and increase the risk of deep vein thrombosis (DVT). This position compresses the femoral veins, hindering blood flow and predisposing the patient to DVT formation. Summary: A: Fowlers position - Not typically associated with increased DVT risk. B: Prone position - Not typically associated with increased DVT risk. C: Supine position - Generally considered a safe position regarding DVT risk.
Question 8 of 9
A nurse is caring for a patient who has had diarrheafor the past week. Which additional assessment finding will the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Decreased skin turgor. Diarrhea leads to fluid loss and dehydration, causing a decrease in skin turgor. Assessing skin turgor by gently pinching the skin on the patient's forearm is important to determine hydration status. A: Distended abdomen is more indicative of possible bowel obstruction or fluid accumulation, not specifically related to diarrhea. C: Increased energy levels are unlikely as diarrhea typically causes fatigue and weakness due to electrolyte imbalance. D: Elevated blood pressure is not a typical finding with diarrhea unless there are other underlying medical conditions.
Question 9 of 9
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patients care, what nursing diagnosis should be prioritized?
Correct Answer: D
Rationale: The correct answer is D: Risk for Impaired Gas Exchange Related to Airway Obstruction. This should be prioritized because hereditary angioedema can lead to swelling in the airway, potentially causing respiratory distress and compromising gas exchange. This nursing diagnosis addresses the immediate threat to the patient's respiratory function. A: Risk for Infection Related to Skin Sloughing - While skin sloughing can occur with hereditary angioedema, it is not the priority over ensuring adequate gas exchange. B: Risk for Acute Pain Related to Loss of Skin Integrity - Pain management is important, but addressing airway obstruction takes precedence due to the potential for respiratory compromise. C: Risk for Impaired Skin Integrity Related to Cutaneous Lesions - Skin integrity issues may be present but do not pose as immediate a threat as airway obstruction.