ATI RN
test bank foundations of nursing Questions
Question 1 of 9
A nurse is caring for a hospitalized patientwith a urinary catheter. Which nursing actionbestprevents the patient from acquiring an infection?
Correct Answer: A
Rationale: The correct answer is A: Maintaining a closed urinary drainage system. This action prevents infection by reducing exposure to external pathogens. Step 1: A closed system minimizes the risk of contamination. Step 2: It prevents entry of bacteria into the urinary tract. Step 3: Regularly emptying the drainage bag helps maintain a closed system. Step 4: This action promotes patient safety and reduces infection risk. Summary: Choice B (strict clean technique) may reduce infection risk during catheter insertion but does not prevent infections post-insertion. Choice C (replacing drainage bag once per shift) increases infection risk due to frequent disconnection. Choice D (fully inflating catheter balloon) is unrelated to infection prevention.
Question 2 of 9
A patient has just been diagnosed with Parkinsons disease and the nurse is planning the patients subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patients family?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. Patients with Parkinson's disease are at risk for falls due to symptoms like tremors and impaired balance. Educating the family about fall prevention measures is crucial. Choice A, Risk for infection, is not directly related to Parkinson's disease. Choice B, Impaired spontaneous ventilation, is not a common concern in Parkinson's disease. Choice C, Unilateral neglect, is more commonly seen in conditions like stroke, not Parkinson's disease. Therefore, the most appropriate nursing diagnosis for the patient with Parkinson's disease is addressing the risk for injury to prevent falls.
Question 3 of 9
A 52-year-old woman has just been told she has breast cancer and is scheduled for a modified mastectomy the following week. The nurse caring for this patient knows that she is anxious and fearful about the upcoming procedure and the newly diagnosed malignancy. How can the nurse most likely alleviate this patients fears?
Correct Answer: B
Rationale: The correct answer is B: Provide the patient with relevant information about expected recovery. This option addresses the patient's anxiety by providing her with concrete information about what to expect after the procedure. By knowing the expected recovery process, the patient can feel more in control and prepared, which can help alleviate fears. Summary: A: Providing written material on the procedure does not directly address the patient's fears about the upcoming surgery and cancer diagnosis. C: Giving the patient current information on breast cancer survival rates may increase anxiety rather than alleviate it, as it focuses on statistics rather than the individual patient's concerns. D: Offering alternative treatment options may not be appropriate at this stage when the patient is already scheduled for a modified mastectomy. It may add confusion and further anxiety.
Question 4 of 9
Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication?
Correct Answer: C
Rationale: The correct answer is C: Normal deep tendon reflexes. This indicates a therapeutic level of magnesium sulfate as it shows that the medication is effectively preventing hyperreflexia, a common sign of magnesium toxicity. Drowsiness (choice A) can indicate toxicity. Urinary output of 20 mL/hour (choice B) is not specific to magnesium sulfate levels. Respiratory rate of 10 to 12 breaths per minute (choice D) is indicative of respiratory depression, a sign of magnesium toxicity. Thus, choice C is the best assessment to indicate a therapeutic level of medication in a patient with preeclampsia taking magnesium sulfate.
Question 5 of 9
A patient newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the patient to implement?
Correct Answer: B
Rationale: The correct answer is B: Sleep on a firm mattress. A firm mattress helps maintain proper spinal alignment, reducing pressure on the cervical spine. This promotes healing and prevents worsening of symptoms. A: Performing active ROM exercises may exacerbate symptoms and worsen the condition. C: Applying cool compresses may provide temporary relief but does not address the underlying issue of spinal alignment. D: Wearing a cervical collar for extended periods can weaken neck muscles and hinder natural healing processes. In summary, sleeping on a firm mattress is the most appropriate conservative measure as it supports proper spinal alignment.
Question 6 of 9
A patient was prescribed an oral antibiotic for the treatment of sinusitis. The patient has now stopped, stating she developed a rash shortly after taking the first dose of the drug. What is the nurses most appropriate response?
Correct Answer: B
Rationale: The correct answer is B: Refer the woman to her primary care provider to have the medication changed. Rationale: 1. Rash after taking the first dose of an antibiotic suggests a possible allergic reaction. 2. Allergic reactions can range from mild to severe, including anaphylaxis. 3. It is crucial to discontinue the suspected medication to prevent worsening of the reaction. 4. Referring the patient to their primary care provider ensures proper evaluation and management. 5. Changing the medication is necessary to avoid potential harm from continued exposure. Summary: A: Continuing the medication can worsen the allergic reaction and is not recommended. C: Going to the emergency department may be excessive at this point for a mild rash. D: Taking an antihistamine does not address the underlying issue of an allergic reaction.
Question 7 of 9
The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Supporting the patients and family's values and choices. In this scenario, the nurse should prioritize respecting the patient's preference to receive care at home and involving the family in decision-making. This approach promotes patient autonomy, dignity, and quality of life. Choice A is incorrect as aggressively fighting the disease process may not align with the patient's wishes for comfort-focused care in hospice. Choice B is incorrect because moving the patient to a long-term care facility goes against the patient's preference to receive care at home. Choice C is not the priority as including the children in planning care is important but not as crucial as respecting the patient's wishes directly.
Question 8 of 9
The nurse is caring for a patient who has just had a radical mastectomy and axillary node dissection. When providing patient education regarding rehabilitation, what should the nurse recommend?
Correct Answer: C
Rationale: The correct answer is C: Avoid lifting objects heavier than 10 pounds. This recommendation is crucial post-mastectomy as it helps prevent lymphedema and promotes healing without causing strain on the surgical site. Lifting heavy objects can lead to complications such as lymphedema or disruption of the healing process. Options A, B, and D are incorrect as avoiding exercise of the arm for 2 months may lead to stiffness and reduced range of motion, keeping cuticles clipped neatly does not directly affect rehabilitation, and using a sling is not necessary unless specifically advised by the healthcare provider.
Question 9 of 9
A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition?
Correct Answer: C
Rationale: The correct answer is C: Sensorineural hearing loss. This type of hearing loss is caused by damage to the inner ear or auditory nerve (cranial nerve VIII). Exostoses (A) are bony growths in the ear canal, not related to cranial nerve VIII. Otalgia (B) refers to ear pain, not hearing loss. Presbycusis (D) is age-related hearing loss, not specifically related to damage of the end organ for hearing or cranial nerve VIII. Therefore, C is the most appropriate term to describe the given condition.