ATI RN
test bank foundations of nursing Questions
Question 1 of 5
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 5
As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that
Correct Answer: A
Rationale: The correct answer is A: immediate birth is required. The Kleihauer–Betke test is used to detect fetal-maternal hemorrhage in situations where there is a risk of fetal blood entering the maternal circulation, such as trauma during pregnancy. A positive result indicates a significant fetal-maternal hemorrhage, which can lead to Rh incompatibility and severe fetal anemia. Immediate birth is required to prevent complications and ensure the safety of both the mother and the baby. Choice B is incorrect as transferring the patient to the critical care unit does not address the underlying issue of fetal-maternal hemorrhage. Choice C is incorrect as RhoGAM is typically administered to prevent Rh sensitization in Rh-negative mothers carrying Rh-positive babies, which is not the primary concern in this scenario. Choice D is incorrect as a tetanus shot is not directly related to the positive Kleihauer–Betke test result indicating fetal-maternal hemorrhage.
Question 3 of 5
Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely cause this abnormality?
Correct Answer: A
Rationale: The correct answer is A: Rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, which includes bilateral cataracts as a characteristic feature. Rubella virus can cross the placenta and affect the developing fetus. Cytomegalovirus (CMV) can also cause congenital cataracts, but rubella is more commonly associated with this abnormality. Syphilis can cause other congenital abnormalities but not bilateral cataracts. HIV does not typically lead to bilateral cataracts in newborns.
Question 4 of 5
Spontaneous termination of a pregnancy is considered to be an abortion if
Correct Answer: A
Rationale: The correct answer is A because spontaneous termination of a pregnancy is considered an abortion if it occurs before 20 weeks gestation. This is based on the medical definition of abortion as the termination of a pregnancy before the fetus is able to survive outside the womb. Choices B, C, and D are incorrect as they do not accurately reflect the criteria for defining abortion. B and D are specific conditions related to the fetus and the presence of infection, while C refers to passing products of conception intact, which can happen in both spontaneous and induced abortions.
Question 5 of 5
The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action isbestfor the nurseto take?
Correct Answer: D
Rationale: Rationale for Correct Answer (D): Checking with the pharmacy for availability of liquid forms of medications is the best action because it reduces the risk of clogging the nasogastric tube. Liquid medications are less likely to cause blockages compared to nonliquid medications. Additionally, liquid forms are easier to administer through the tube. By using liquid medications, the nurse can ensure that the medications flow smoothly through the tube without causing any obstructions. Summary of Incorrect Choices: A: Instilling nonliquid medications without diluting can increase the risk of tube clogging. B: Irrigating the tube with water after all medications are given may not prevent clogging effectively and could introduce unnecessary moisture into the tube. C: Mixing all medications together can lead to potential drug interactions and may not address the issue of tube clogging effectively.