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 patient presents at the ED after receiving a chemical burn to the eye. What would be the nurses initial intervention for this patient?
Correct Answer: B
Rationale: The correct initial intervention for a chemical burn to the eye is to generously flush the affected eye with normal saline or water. Flushing helps to remove the chemical from the eye, preventing further damage. Antibiotic solution (choice A) is not the first intervention as the priority is to remove the chemical. Applying a patch (choice C) can trap the chemical against the eye, worsening the injury. Applying direct pressure (choice D) is not appropriate and can cause additional harm. Flushing with normal saline or water is the most effective and safest initial intervention to minimize damage from a chemical burn to the eye.
Question 3 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.
Question 4 of 9
A patient, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease?
Correct Answer: C
Rationale: The correct answer is C: Emotional and personality changes. In Huntington disease, neurodegeneration affects the brain, leading to changes in behavior, emotions, and personality. These changes are characteristic of the disease progression. Metastasis (A) refers to the spread of cancer, which is not associated with Huntington disease. Risk for stroke (B) is not a typical manifestation of Huntington disease. Pathologic bone fractures (D) are not directly related to the primary symptoms of Huntington disease. Thus, addressing emotional and personality changes is crucial in providing anticipatory guidance for individuals with Huntington disease.
Question 5 of 9
A woman calls the clinic and tells the nurse she has had bloody drainage from her right nipple. The nurse makes an appointment for this patient, expecting the physician or practitioner to order what diagnostic test on this patient?
Correct Answer: A
Rationale: The correct answer is A: Breast ultrasound. Bloody drainage from the nipple can be indicative of various conditions such as breast cancer. A breast ultrasound is a non-invasive imaging test that can help visualize any abnormalities in the breast tissue, including masses or tumors. It is commonly used to evaluate breast symptoms like nipple discharge. Radiography (B) is not typically used for evaluating breast conditions. Positron emission testing (PET) (C) is more commonly used in cancer staging and may not be the first-line test for this symptom. Galactography (D) is a specific imaging test used to evaluate the ducts of the breast and may not be the initial test for bloody nipple discharge.
Question 6 of 9
The nurse on the medicalsurgical unit is reviewing discharge instructions with a patient who has a history of glaucoma. The nurse should anticipate the use of what medications?
Correct Answer: B
Rationale: The correct answer is B: Cholinergics. Glaucoma is a condition characterized by increased intraocular pressure due to impaired drainage of aqueous humor. Cholinergics help to constrict the pupil and improve the outflow of aqueous humor, thus reducing intraocular pressure. This medication class is commonly used to manage glaucoma. A: Potassium-sparing diuretics are not typically used in the treatment of glaucoma. They are mainly used to manage conditions like hypertension and heart failure. C: Antibiotics are not indicated for the routine management of glaucoma. They are used to treat infections. D: Loop diuretics are not commonly used in the treatment of glaucoma. They are primarily used to manage conditions like edema and hypertension.
Question 7 of 9
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
Correct Answer: B
Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention. Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B. Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B. Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.
Question 8 of 9
A nurse is caring for a patient who has had diarrhea for 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, causing dehydration and decreased skin turgor. This indicates the patient's hydration status. A: Distended abdomen is more common in conditions like bowel obstruction, not necessarily in diarrhea. C: Increased energy levels are unlikely due to the patient's weakened state from dehydration. D: Elevated blood pressure is not typically associated with dehydration.
Question 9 of 9
A placenta previa when the placental edge just reaches the internal os is called
Correct Answer: D
Rationale: The correct answer is D, marginal. Placenta previa is classified based on the proximity of the placental edge to the internal os. In a marginal placenta previa, the placental edge just reaches the internal os. This is a crucial distinction as it poses a higher risk for bleeding during labor. Total placenta previa covers the entire internal os, partial placenta previa partially covers the internal os, and low-lying placenta is when the placenta is close to but not covering the internal os. Therefore, D is correct as it accurately describes the specific position of the placenta edge in relation to the internal os in cases of marginal placenta previa.