ATI RN
foundations of nursing test bank Questions
Question 1 of 9
A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Serum albumin level. Serum albumin is an important indicator of nutritional status, as low levels may indicate malnutrition or inflammation commonly seen in AIDS patients. Weight history (B) is also relevant as weight changes can reflect nutritional status. White blood cell count (C) is not directly related to nutritional status. Body mass index (D) is a calculation based on weight and height, not a direct measure of nutritional status. Blood urea nitrogen (E) is a measure of kidney function, not a specific indicator of nutritional status. Therefore, the nurse should primarily focus on assessing the patient's serum albumin level for nutritional status evaluation in this case.
Question 2 of 9
A nursing student is learning how to perform sexual assessments using the PLISSIT model. According to this model, the student should begin an assessment by doing which of the following?
Correct Answer: D
Rationale: The correct answer is D: Ensuring patient privacy. In the PLISSIT model, ensuring patient privacy is crucial as it creates a safe and confidential environment for discussing sensitive topics like sexual health. This step helps build trust and allows the patient to feel comfortable sharing intimate details. Briefly teaching about normal sexual physiology (A) may come later in the assessment process. Assuring confidentiality (B) is important but doesn't address the immediate need for privacy. Asking if the patient is willing to discuss sexual functioning (C) assumes patient readiness without first establishing a private setting.
Question 3 of 9
An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?
Correct Answer: D
Rationale: Correct Answer: D - Avoid rubbing or scratching the affected area Rationale: 1. Rubbing or scratching can further damage the already compromised skin integrity. 2. By avoiding rubbing or scratching, the patient reduces the risk of infection and delayed healing. 3. This intervention promotes skin healing and prevents worsening of the condition. Summary: A: Applying ice pack or heating pad may provide temporary relief but does not address the root cause of impaired skin integrity. B: Avoiding skin contact with water is not necessary and may not directly improve skin integrity. C: Phototherapy is not indicated for erythematous reactions to radiation therapy and may not address the issue.
Question 4 of 9
A nurse is charting on a patient’s record. Whichaction will the nurse take that is accurate legally?
Correct Answer: A
Rationale: The correct answer is A: Charts legibly. This is accurate legally because clear and legible documentation is crucial for accurately conveying patient information, ensuring continuity of care, and meeting legal standards. Illegible handwriting can lead to errors in patient care and legal issues. Choice B is incorrect as labeling a patient as "belligerent" without evidence can be perceived as unprofessional and potentially harmful to the patient. Choice C is incorrect as writing an entry for another nurse can lead to inaccurate documentation and legal consequences. Choice D is incorrect because using correction fluid can raise suspicion of tampering with records and compromise the integrity of the documentation.
Question 5 of 9
Which maternal condition always necessitates delivery by cesarean birth?
Correct Answer: B
Rationale: The correct answer is B: Total placenta previa. In this condition, the placenta completely covers the cervix, posing a risk of severe bleeding during vaginal delivery. Cesarean birth is necessary to avoid potential life-threatening complications for both the mother and the baby. Partial abruptio placentae (choice A) involves premature separation of the placenta, but it doesn't always require a cesarean birth. Ectopic pregnancy (choice C) occurs when the fertilized egg implants outside the uterus, typically requiring surgical intervention but not always a cesarean birth. Eclampsia (choice D) is a serious condition characterized by high blood pressure and seizures, but it doesn't always necessitate cesarean birth unless there are other complications that require it.
Question 6 of 9
A laboratory finding indicatiNveU oRf SDIICN iGs oTnBe .thCatO sMhows
Correct Answer: A
Rationale: The correct answer is A: decreased fibrinogen. In disseminated intravascular coagulation (DIC), there is widespread activation of coagulation leading to consumption of clotting factors like fibrinogen, resulting in decreased levels. Platelets are usually decreased, not increased, in DIC. Hematocrit may be elevated due to hemoconcentration but not directly related to DIC. Thromboplastin time would be prolonged, not decreased, in DIC due to consumption of clotting factors.
Question 7 of 9
A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style. A home health nurse is preparing for an initialhome visit. Which information should be included in the patient’s home care medical record?
Correct Answer: D
Rationale: The correct answer is D: Reports to third-party payers. In home health care, it is essential to document and report patient care to third-party payers for reimbursement purposes. This includes detailed reports on the services provided, patient progress, and any changes in the care plan. This information is crucial for ensuring that the patient receives appropriate reimbursement for the care received. Incorrect choices: A: Nursing process form - While a nursing process form is important for documenting patient care, it is not specifically related to reporting to third-party payers. B: Step-by-step skills manual - While a skills manual may be helpful for guiding care provision, it is not typically included in the patient's medical record. C: A list of possible procedures - While a list of procedures may be useful for reference, it is not a formal part of the patient's medical record for home care documentation.
Question 8 of 9
The nurse is concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is thepriority?
Correct Answer: B
Rationale: The correct answer is B because verifying tube placement before feeding is essential to prevent pulmonary aspiration. If the tube is not correctly positioned in the stomach, there is a risk of feeding going into the lungs. Observing the color of gastric contents (A) may not always indicate correct placement. Adding blue food coloring (C) is unnecessary and could cause confusion. Running the formula over 12 hours (D) does not address the risk of pulmonary aspiration and does not ensure proper tube placement.
Question 9 of 9
A nurse is reviewing results from a urine specimen.What will the nurse expect to see in a patient with a urinary tract infection?
Correct Answer: D
Rationale: The correct answer is D: Bacteria. In a patient with a urinary tract infection (UTI), bacteria are typically present in the urine due to the infection of the urinary system. Bacteria may be detected through urine culture or microscopic examination. A: Casts are not typically associated with UTIs but can indicate kidney disease. B: Protein in the urine can indicate kidney damage or other issues, not specific to UTIs. C: Crystals in the urine can be normal or indicate specific conditions, but they are not specific to UTIs. In summary, the presence of bacteria in the urine is a key indicator of a UTI, while the other choices are more indicative of different conditions or factors.