ATI RN
foundation of nursing questions Questions
Question 1 of 5
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
Correct Answer: B
Rationale: The correct answer is B: Thigh. When administering epinephrine during an anaphylactic reaction, the thigh is the recommended site due to its large muscle mass and quick absorption rate. Steps: 1. Remove safety cap. 2. Firmly push the auto-injector against the thigh until it clicks. 3. Hold in place for a few seconds. 4. Seek medical help immediately. Rationale for incorrect choices: A: Forearm - Not recommended due to smaller muscle mass and slower absorption. C: Deltoid muscle - Not preferred as it may not provide as rapid absorption as the thigh. D: Abdomen - Not ideal due to potential fat layers that could affect absorption speed.
Question 2 of 5
A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patients condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Foods. Anaphylaxis is a severe allergic reaction that can be triggered by foods, medications, insect stings, and other allergens. In this scenario, assessing for potential food allergies is crucial as food is one of the most common triggers for anaphylaxis. Foods like nuts, shellfish, and eggs are common culprits. Medications and insect stings (choices B and C) are also important triggers to consider in the assessment. Autoimmunity (choice D) is not a direct cause of anaphylaxis, as it involves the immune system attacking the body's own tissues rather than reacting to external allergens. Environmental pollutants (choice E) may trigger respiratory symptoms but are not typically associated with anaphylaxis.
Question 3 of 5
A child has been transported to the emergency department (ED) after a severe allergic reaction. The ED nurse is evaluating the patients respiratory status. How should the nurse evaluate the patients respiratory status? Select all that apply.
Correct Answer: B
Rationale: Rationale: Assessing breath sounds is crucial in evaluating respiratory status as it helps identify any signs of airway obstruction or respiratory distress. This includes listening for wheezing, crackles, or diminished breath sounds. Lung function testing (A) may not be feasible in an acute emergency situation. Oxygen saturation (C) is important but does not provide a comprehensive assessment of respiratory status. Monitoring respiratory pattern (D) and assessing respiratory rate (E) are important but do not directly assess breath sounds, which are vital in identifying immediate respiratory issues.
Question 4 of 5
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.
Question 5 of 5
While taking a health history on a 20-year-old female patient, the nurse ascertains that this patient is taking miconazole (Monistat). The nurse is justified in presuming that this patient has what medical condition?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): The nurse can presume the patient has candidiasis since miconazole is commonly used to treat fungal infections like vaginal yeast infections caused by Candida. This medication works by stopping the growth of the fungus. Therefore, the patient's use of miconazole indicates a probable diagnosis of candidiasis. Summary of Incorrect Choices: A (Bacterial vaginosis): Miconazole is not used to treat bacterial infections like bacterial vaginosis, which is caused by an imbalance of bacteria in the vagina. B (HPV): Miconazole is not used to treat viral infections like HPV, which is a sexually transmitted infection caused by certain types of human papillomavirus. D (TSS): Miconazole is not used to treat toxic shock syndrome, which is a severe complication of certain bacterial infections and is not typically associated with miconazole use.