ATI RN
test bank foundations of nursing Questions
Question 1 of 9
A nurse practitioner is examining a patient who presented at the free clinic with vulvar pruritus. For which assessment finding would the practitioner look that may indicate the patient has an infection caused by Candida albicans?
Correct Answer: A
Rationale: The correct answer is A: Cottage cheese-like discharge. Candida albicans is a common cause of vulvovaginal candidiasis, characterized by itching and cottage cheese-like discharge. This type of discharge is specific to a yeast infection. Yellow-green discharge (choice B) is indicative of trichomoniasis, gray-white discharge (choice C) is seen in bacterial vaginosis, and watery discharge with a fishy odor (choice D) is characteristic of bacterial vaginosis or trichomoniasis. Therefore, the presence of cottage cheese-like discharge is a key indicator of a Candida albicans infection.
Question 2 of 9
A patient has just been diagnosed with Parkinsons disease and the nurse is planning the patients subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patients family?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. Patients with Parkinson's disease are at risk for falls due to symptoms like tremors and impaired balance. Educating the family about fall prevention measures is crucial. Choice A, Risk for infection, is not directly related to Parkinson's disease. Choice B, Impaired spontaneous ventilation, is not a common concern in Parkinson's disease. Choice C, Unilateral neglect, is more commonly seen in conditions like stroke, not Parkinson's disease. Therefore, the most appropriate nursing diagnosis for the patient with Parkinson's disease is addressing the risk for injury to prevent falls.
Question 3 of 9
A 35-year-old mother of three young children has been diagnosed with stage II breast cancer. After discussing treatment options with her physician, the woman goes home to talk to her husband, later calling the nurse for clarification of some points. The patient tells the nurse that the physician has recommended breast conservation surgery followed by radiation. The patients husband has done some online research and is asking why his wife does not have a modified radical mastectomy to be sure all the cancer is gone. What would be the nurses best response?
Correct Answer: D
Rationale: The correct answer is D: According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy. 1. Breast conservation surgery followed by radiation is a standard treatment option for early-stage breast cancer. 2. Studies have shown that breast conservation surgery combined with radiation therapy is equally effective in terms of long-term survival rates compared to mastectomy. 3. Current guidelines recommend considering breast conservation surgery as a viable option for patients with early-stage breast cancer. 4. Modified radical mastectomy is not necessarily needed to ensure complete removal of cancer, as breast conservation surgery followed by radiation can achieve the same goal. 5. Therefore, the nurse should reassure the patient's husband that the recommended treatment plan is based on current guidelines and is as effective as a modified radical mastectomy.
Question 4 of 9
A patient has presented for her annual mammogram. The patient voices concerns related to exposure to radiation. What should the nurse teach the patient about a mammogram?
Correct Answer: A
Rationale: Step 1: Mammograms use low-dose X-rays to create images of the breast tissue. Step 2: The radiation exposure in a mammogram is minimal and considered safe. Step 3: Choice A is correct as it states that mammograms do not use radiation, which is accurate. Step 4: Other choices are incorrect because B wrongly implies that annual mammograms are safe due to low radiation levels, C is incorrect as radiation effects can accumulate over time, and D is incorrect as the amount of radiation in a mammogram is much lower than an hour of sunlight.
Question 5 of 9
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?
Correct Answer: C
Rationale: The correct answer is C because putting on a second pair of gloves over soiled gloves during a procedure violates standard precautions by increasing contamination risk. Here's the rationale: 1. Standard precautions require removing soiled gloves before putting on new ones to prevent cross-contamination. 2. Wearing multiple gloves increases the risk of tearing and exposure to pathogens. 3. This behavior shows a lack of understanding of proper infection control practices. Summary of other choices: A: Wearing face protection, gloves, and a gown when irrigating a wound is a correct practice. B: Washing hands with waterless antiseptic after removing soiled gloves is correct. D: Placing a used needle and syringe in a puncture-resistant container without capping the needle is incorrect, but not as severe as choice C.
Question 6 of 9
A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching?
Correct Answer: A
Rationale: Correct Answer: A - Care of the cervical collar Rationale: 1. Care of the cervical collar is essential post-cervical diskectomy to ensure proper immobilization and support. 2. Proper care prevents complications and promotes healing. 3. It is a crucial aspect of discharge education to prevent injury and promote recovery. Summary of other choices: B: Technique for performing neck ROM exercises - Important for rehabilitation but not directly related to discharge education post-cervical diskectomy. C: Home assessment of ABGs - Irrelevant to post-cervical diskectomy discharge education. D: Techniques for restoring nerve function - Important for recovery but not a primary focus of discharge education.
Question 7 of 9
A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education?
Correct Answer: B
Rationale: The correct answer is B: Compensating for vision loss for the next several weeks. This is the priority subject for discharge education because vision loss is a common outcome post vitreoretinal procedure. The patient needs to understand how to adapt to this temporary impairment, such as using assistive devices and modifying their environment. A: Risk factors for postoperative CMV is not the priority as it is not a common concern in this situation. C: Non-pharmacologic pain management is important but not the priority compared to vision loss. D: Signs and symptoms of increased intraocular pressure are important but not as crucial as managing vision loss.
Question 8 of 9
The nurse is admitting a patient to the unit who is scheduled to have an ossiculoplasty. What postoperative assessment will best determine whether the procedure has been successful?
Correct Answer: B
Rationale: The correct answer is B: Audiometry. Postoperative audiometry is the most appropriate assessment to determine the success of ossiculoplasty, as it evaluates the patient's hearing function and any improvements made by the surgery. Otoscopy (A) is a visual examination of the ear canal and may not provide comprehensive information on hearing. Balance testing (C) assesses equilibrium and is not directly related to the success of ossiculoplasty. Culture and sensitivity testing (D) of ear discharge is used to identify infections and would not directly indicate the success of the surgery.
Question 9 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.