ATI RN
test bank foundations of nursing Questions
Question 1 of 9
A nurse is planning the care of a patient with AIDS who is admitted to the unit withPneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?
Correct Answer: A
Rationale: The correct answer is A: Ineffective Airway Clearance. In a patient with AIDS and PCP, maintaining clear airways is crucial to prevent respiratory distress and hypoxia. Pneumocystis pneumonia can cause thick secretions and mucus plugging, leading to difficulty breathing. Ensuring effective airway clearance is a priority to optimize oxygenation and prevent respiratory complications. Impaired oral mucous membranes (B) and imbalanced nutrition (C) are important considerations but not as immediate as airway clearance. Activity intolerance (D) may be a concern for the patient but ensuring adequate oxygenation takes precedence.
Question 2 of 9
A nurse is describing the purposes of a healthcare record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all thatapply.)
Correct Answer: A
Rationale: The correct answer is A: Communication. Healthcare records are essential for effective communication among healthcare providers to ensure continuity of care. They help convey important information about a patient's condition, treatment plan, and progress. Explanation: 1. Communication: Healthcare records facilitate communication between different healthcare team members, ensuring coordinated and efficient care delivery. 2. Legal documentation: While important, legal documentation is a separate purpose of healthcare records, not directly related to communication. 3. Reimbursement: Healthcare records are used for billing and reimbursement purposes, but this is not directly related to communication. 4. Nursing process: The nursing process involves assessment, diagnosis, planning, implementation, and evaluation of patient care, which is documented in healthcare records. However, this is not a primary purpose related to communication.
Question 3 of 9
The nurse is preparing to check the gastric aspirate for pH. Which equipment will the nurse obtain?
Correct Answer: A
Rationale: The correct answer is A: 10-mL Luer-Lok syringe. The nurse should use this syringe to obtain a gastric aspirate for pH testing because it allows for accurate measurement of the aspirate volume. Asepto syringe (B) is not suitable for this purpose as it is not designed for accurate measurement. Sterile gloves (C) and double gloves (D) are not equipment used specifically for obtaining gastric aspirate for pH testing. Sterile gloves are used for infection control, and double gloves are used for additional protection during procedures.
Question 4 of 9
A nurse is reviewing urinary laboratory results.Which finding will cause the nurse to follow up?
Correct Answer: A
Rationale: The correct answer is A because a protein level of 2 mg/100 mL in urine indicates proteinuria, which can be a sign of kidney dysfunction or other underlying health issues. The nurse should follow up to assess further for possible kidney disease or other conditions. Choice B is not a cause for concern as a urine output of 80 mL/hr is within the normal range. Choice C indicates concentrated urine, which may be due to dehydration but does not necessarily require immediate follow-up. Choice D is within the normal range for urine pH and does not typically warrant immediate follow-up.
Question 5 of 9
As the American population ages, nurses expect see more patients admitted to long-term care facilities in need of palliative care. Regulations now in place that govern how the care in these facilities is both organized and reimbursed emphasize what aspect of care?
Correct Answer: D
Rationale: The correct answer is D: Incentives to palliative care. Palliative care focuses on improving the quality of life for patients with serious illnesses by addressing their physical, emotional, and spiritual needs. As the American population ages, the emphasis on palliative care in long-term care facilities is crucial. Regulations emphasizing incentives for palliative care ensure that patients receive appropriate symptom management, comfort care, and support to enhance their overall well-being. Choice A: Ongoing acute care is not the correct answer because palliative care is different from acute care, which focuses on treating the underlying medical condition. Choice B: Restorative measures are not the correct answer as palliative care aims to improve quality of life rather than focusing on restoring physical function. Choice C: Mobility and socialization are important aspects of care in long-term facilities, but palliative care goes beyond these aspects to provide holistic support for patients facing serious illnesses.
Question 6 of 9
A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication?
Correct Answer: B
Rationale: The correct answer is B: The patient should be monitored for bone marrow depression. Carbamazepine can cause bone marrow suppression, leading to decreased production of blood cells. Monitoring blood counts is crucial to detect this adverse effect early. Choice A is incorrect as Tegretol can have serious adverse effects, including bone marrow depression. Choice C is incorrect as the main side effects of carbamazepine are related to the central nervous system, not renal dysfunction. Choice D is incorrect as medications like carbamazepine should be started at a low dose and gradually titrated up to minimize side effects.
Question 7 of 9
The nurse is writing a care plan for a patient with brain metastases. The nurse decides that an appropriate nursing diagnosis is anxiety related to lack of control over the health circumstances. In establishing this plan of care for the patient, the nurse should include what intervention?
Correct Answer: C
Rationale: The correct answer is C because encouraging the patient to verbalize concerns can help alleviate anxiety by allowing the patient to express emotions and fears. This intervention promotes emotional expression and provides an outlet for the patient to discuss their worries. This can lead to increased understanding and support. Incorrect answers: A: Administering antianxiety medications does not address the underlying cause of anxiety and may lead to dependency. B: Instructing the family on planning care does not directly address the patient's anxiety. D: Distracting the patient may provide temporary relief but does not address the root cause of anxiety related to lack of control over health circumstances.
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 nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
Correct Answer: A
Rationale: The correct answer is A: Perianal region and oral mucosa. In patients with AIDS, these areas are more prone to opportunistic infections due to decreased immune function. The perianal region can be affected by conditions like anal warts or herpes, while the oral mucosa can develop oral thrush or other oral infections. By prioritizing assessment of these areas, the nurse can promptly identify any potential issues and initiate appropriate interventions. Choice B: Sacral region and lower abdomen are not typically high-risk areas for skin integrity issues in AIDS patients. Choice C: Scalp and skin over the scapulae are not commonly affected by opportunistic infections related to AIDS. Choice D: Axillae and upper thorax are not as commonly affected as the perianal region and oral mucosa in AIDS patients.