ATI RN
foundation of nursing questions Questions
Question 1 of 9
A nurse is aware of the need to assess patients risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis?
Correct Answer: C
Rationale: The correct answer is C: Computed tomography with contrast solution. This procedure involves the use of contrast agents that can trigger anaphylaxis due to the patient's allergic reaction to the contrast solution. Contrast solutions contain substances like iodine, which can cause severe allergic reactions in some individuals. Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and requires immediate intervention. Assessing the risk for anaphylaxis during this procedure is crucial to prevent any potential harm to the patient. Incorrect choices: A: Administration of the measles-mumps-rubella (MMR) vaccine - While allergic reactions can occur with vaccines, the risk of anaphylaxis with MMR vaccine is lower compared to the contrast solution used in CT scans. B: Rapid administration of intravenous fluids - Rapid IV fluid administration can cause fluid overload or electrolyte imbalances, but it is not typically associated with triggering anaphylaxis. D: Administration of nebulized bronchodil
Question 2 of 9
A nurse is completing an OASIS data set on apatient. The nurse works in which area?
Correct Answer: A
Rationale: The correct answer is A: Home health. The Outcome and Assessment Information Set (OASIS) data set is specifically used in the home health care setting to assess the patient's condition and needs. This includes collecting data on the patient's health, functional status, and living environment to determine the appropriate care plan. In contrast, choices B, C, and D are incorrect because OASIS is not utilized in the intensive care unit, skilled nursing facility, or long-term care facility settings. These settings have their own assessment tools and documentation requirements that are different from OASIS used in home health care.
Question 3 of 9
A clinic nurse is providing preprocedure education for a man who will undergo a vasectomy. Which of the following measures will enhance healing and comfort? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Abstaining from sexual intercourse for at least 14 days postprocedure. This is important to allow the surgical site to heal properly and reduce the risk of complications. Choice B, wearing a scrotal support garment, can provide comfort but does not directly enhance healing. Choice C, using sitz baths, may help with discomfort but may not specifically promote healing. Choice D, applying a heating pad intermittently, could potentially increase the risk of infection. Choice E, staying on bed rest for 48 to 72 hours postprocedure, is unnecessary and could lead to complications such as blood clots.
Question 4 of 9
A patient at high risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the patient asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurses best response?
Correct Answer: B
Rationale: The correct answer is B because an incisional biopsy is typically performed to confirm a diagnosis by obtaining a sample of the tissue in question. This allows for further analysis through special studies to determine the best course of treatment. The other choices are incorrect because: A: The reason for performing an incisional biopsy is not primarily based on pain or accuracy comparisons with other testing methods. C: An incisional biopsy is not done to assess potential recovery from a mastectomy but rather to diagnose the nature of the mass. D: Age and general health status are not sole criteria for determining the need for an incisional biopsy.
Question 5 of 9
An oncology patient has just returned from the postanesthesia care unit after an open hemicolectomy. This patients plan of nursing care should prioritize which of the following?
Correct Answer: C
Rationale: The correct answer is C because assessing the patient's wound for dehiscence every 4 hours is crucial post hemicolectomy to monitor for any signs of wound complications, such as infection or tissue breakdown. This allows for early detection and intervention, promoting optimal wound healing and preventing potential complications. Choice A is incorrect as compartment syndrome is not a common complication after a hemicolectomy, and assessing for it hourly would be excessive and unnecessary. Choice B is incorrect as assessing fine motor skills is not a priority in the immediate postoperative period following a hemicolectomy. Choice D is incorrect as maintaining the patient's head of bed at 45 degrees or more is important for preventing respiratory complications, but it is not the top priority compared to wound assessment for dehiscence in this scenario.
Question 6 of 9
The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action?
Correct Answer: B
Rationale: The correct answer is B: Assisting the patient into a sitting position. The Epley maneuver is used to treat benign paroxysmal positional vertigo by repositioning displaced calcium carbonate crystals in the inner ear. This maneuver involves a series of specific head movements. Starting with the patient in a sitting position allows for proper orientation and positioning for subsequent movements to be effective. Placing the patient in a prone position (A) would not facilitate the correct positioning for the maneuver. Instilling warm saline into the ear (C) is not part of the Epley maneuver. Assessing baseline hearing (D) is unrelated to performing the Epley maneuver.
Question 7 of 9
A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patients family and friends?
Correct Answer: D
Rationale: The correct answer is D: Do not visit if you've had a recent infection. This is crucial to prevent the transmission of infections to the patient, who will have a compromised immune system post-HSCT. Family and friends with recent infections can pose a serious risk to the patient's health. Choice A is incorrect because it instills fear and negativity in the family without providing any tangible benefits. Choice B is incorrect as fasting is not typically required before a HSCT and can be harmful to the patient's nutritional status. Choice C is incorrect as wearing a hospital gown is generally not necessary for visitors, unless specified by the healthcare team for infection control purposes.
Question 8 of 9
Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?
Correct Answer: A
Rationale: The correct answer is A: Hypoglycemia. Infants of diabetic mothers are at risk for hypoglycemia due to excessive insulin production in response to high glucose levels in utero. Monitoring blood glucose levels is crucial to prevent hypoglycemia-related complications. B: Hypercalcemia is not a major neonatal complication seen in infants of diabetic mothers. C: Hypoinsulinemia refers to low levels of insulin, which is not typically a concern in infants of diabetic mothers. D: Hypobilirubinemia is not a common complication in infants of diabetic mothers. In summary, monitoring for hypoglycemia is essential in infants of diabetic mothers to prevent potential complications.
Question 9 of 9
The advanced practice nurse is attempting to examine the patients ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patients ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure?
Correct Answer: A
Rationale: Correct Answer: A. Maintain the irrigation fluid at a warm temperature. Rationale: 1. Warm fluid helps prevent vertigo and nausea by minimizing stimulation of the vestibular system. 2. Cold fluid can cause dizziness and nausea due to the temperature effect on the inner ear. 3. Warm fluid promotes patient comfort and relaxation during the procedure. 4. Cold fluid can lead to vasoconstriction, potentially exacerbating ear discomfort. Summary of other choices: B. Instilling short, sharp bursts of fluid can be uncomfortable and increase the risk of vertigo and nausea. C. Following with a curette may not be necessary if the irrigation effectively removes the impacted cerumen. D. Having the patient stand can increase the risk of falling or losing balance due to potential dizziness from the procedure.