ATI RN
foundations of nursing test bank Questions
Question 1 of 9
A nurse is checking orders. Which order shouldthe nurse question?
Correct Answer: B
Rationale: The correct answer is B because giving a hypertonic solution enema to a patient with fluid volume excess can worsen the condition by drawing more fluid into the colon. This can lead to further fluid volume overload and electrolyte imbalances. The other choices are incorrect because: A: Normal saline enema is appropriate for constipation. C: Kayexalate enema is used to treat hyperkalemia, not hypokalemia. D: Oil retention enema is indicated for constipation to soften stool.
Question 2 of 9
The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?
Correct Answer: D
Rationale: The correct answer is D: Mobility. A malignant breast tumor typically lacks mobility due to its fixed attachment to surrounding tissues. This characteristic is concerning for malignancy as it suggests invasive growth. Incorrect answers: A: Nontenderness - Tenderness does not reliably indicate malignancy or benignancy. B: A size of 5 mm - Tumor size alone does not determine malignancy. C: Softness and a regular shape - Malignant tumors are often firm and irregular in shape.
Question 3 of 9
A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond?
Correct Answer: C
Rationale: The correct answer is C because it accurately explains the physiological change in the eye that leads to the need for bifocals. As individuals age, there is a gradual thickening of the lens of the eye, which affects the eye's ability to accommodate for near vision. This thickening makes it harder for the eye to focus on close objects, necessitating the use of bifocals to correct this near vision issue. Choices A, B, and D are incorrect because they do not provide a scientifically accurate explanation for the need for bifocals in older individuals. Option A is dismissive and does not address the specific change in the eye that leads to the need for bifocals. Option B implies aging as a general concept without specifying the relevant change in the eye. Option D incorrectly states that the eye gets shorter as we age, which is not the reason for needing bifocals.
Question 4 of 9
A patient in her 30s has two young children and has just had a modified radical mastectomy with immediate reconstruction. The patient shares with the nurse that she is somewhat worried about her future, but she appears to be adjusting well to her diagnosis and surgery. What nursing intervention is most appropriate to support this patients coping?
Correct Answer: D
Rationale: The correct answer is D, which is to arrange a referral to a community-based support program. This option is the most appropriate because it offers the patient ongoing support from individuals who understand what she is going through. Community-based support programs can provide a safe space for the patient to share her feelings, connect with others in similar situations, and access additional resources for coping. This intervention focuses on providing the patient with adequate support beyond the immediate recovery period, which is crucial for long-term coping and adjustment. Option A is incorrect as it may not consider the patient's individual needs for support beyond her spouse or partner. Option B may be premature as the patient might need time to process her diagnosis and surgery before moving on to the next phase of treatment. Option C may put undue pressure on the patient to maintain a specific emotional state for the sake of others, which may not be beneficial for her own coping and healing process.
Question 5 of 9
The nurse is teaching a health class about theChooseMyPlateprogram. Which guidelines will thenurse include in the teaching session?
Correct Answer: D
Rationale: The correct answer is D, balancing calories. This is because the ChooseMyPlate program emphasizes the importance of maintaining a balance between the calories consumed and calories expended for overall health and weight management. By balancing calories, individuals can ensure they are meeting their nutritional needs without overeating or consuming excess calories. A: Balancing sodium and potassium is important for managing blood pressure, but this is not a specific guideline of the ChooseMyPlate program. B: Decreasing water consumption is not a guideline of the ChooseMyPlate program. Adequate hydration is essential for overall health. C: Increasing portion size is not recommended in the ChooseMyPlate program. It emphasizes portion control and eating appropriate serving sizes of different food groups.
Question 6 of 9
A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patients diagnosis will be?
Correct Answer: D
Rationale: The correct answer is D: Labyrinthitis. This condition presents with sudden onset vertigo, nausea, vomiting, tinnitus, and hearing loss, which are all symptoms described by the patient. Labyrinthitis is commonly caused by a viral infection affecting the inner ear, leading to inflammation of the labyrinth. This inflammation disrupts the balance and hearing functions of the inner ear, resulting in the symptoms mentioned. A: Ossiculitis involves inflammation of the middle ear bones, typically causing conductive hearing loss, not the sudden onset of vertigo and other symptoms described. B: Mnire's disease is characterized by recurrent episodes of vertigo, tinnitus, and hearing loss, but it typically does not present with sudden onset incapacitating vertigo. C: Ototoxicity is caused by exposure to certain medications or chemicals that damage the inner ear structures, leading to hearing loss. While hearing loss is a symptom, the sudden onset of vertigo is not typically associated with ototoxicity.
Question 7 of 9
A woman is being treated for a tumor of the left breast. If the patient and her physician opt for prophylactic treatment, the nurse should prepare the woman for what intervention?
Correct Answer: D
Rationale: The correct answer is D: Bilateral mastectomy. This intervention involves removing both breasts to reduce the risk of developing breast cancer in the future. For a woman with a history of breast cancer in one breast, opting for bilateral mastectomy can significantly decrease the likelihood of cancer recurrence. This proactive approach is often recommended for individuals with a high risk of developing breast cancer. Explanation for why the other choices are incorrect: A: More aggressive chemotherapy - Chemotherapy is typically used to treat existing cancer cells, not as a prophylactic measure to prevent cancer. B: Left mastectomy - This option only removes the affected breast, not addressing the risk of cancer developing in the other breast. C: Radiation therapy - While radiation therapy can be used as part of the treatment for breast cancer, it is not a prophylactic measure to prevent future cancer development in the contralateral breast.
Question 8 of 9
A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL.
Correct Answer: C
Rationale: The correct answer is C (900 mL) because the weight of 900 g corresponds to a blood loss of the same amount in milliliters. Blood density is close to that of water, so 1 g ≈ 1 mL. Therefore, a blood-soaked peripad weighing 900 g indicates a blood loss of 900 mL. Choice A (1800 mL) is incorrect as it doubles the weight instead of converting it to milliliters. Choice B (450 mL) is incorrect as it halves the weight. Choice D (90 mL) is incorrect as it divides the weight by 10, which is too small for the blood loss indicated.
Question 9 of 9
A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Application of topical antibiotic ointment. After enucleation, there is a risk of infection at the surgical site. By applying topical antibiotic ointment as directed, the patient can help prevent infection and promote healing. This is a crucial aspect of postoperative care. B: Maintenance of a supine position for the first 48 hours postoperative is incorrect. Patients may be advised to avoid lying flat on their back to prevent complications such as pressure on the surgical site. C: Fluid restriction to prevent orbital edema is incorrect. Fluid restriction is not typically necessary post-enucleation unless specifically advised by the healthcare provider. D: Administration of loop diuretics to prevent orbital edema is incorrect. Loop diuretics are not typically used for preventing orbital edema post-enucleation. E: Use of an ocular pressure dressing is incorrect. While dressings may be used postoperatively, the application of topical antibiotic ointment is more