ATI RN
test bank foundations of nursing Questions
Question 1 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 2 of 9
A nurse knows of several patients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which patient?
Correct Answer: B
Rationale: The correct answer is B. Antihistamines are generally considered safe during pregnancy, but it is recommended to avoid unnecessary medications, especially in the third trimester. Antihistamines should be used cautiously in pregnant women due to potential effects on the fetus. Choice A is incorrect because previous treatment for tuberculosis does not contraindicate the use of antihistamines. Choice C is incorrect as estrogen-replacement therapy does not interact significantly with antihistamines. Choice D is incorrect as a severe allergy to eggs does not directly contraindicate the use of antihistamines.
Question 3 of 9
A nurse is caring for a 33-year-old male who has come to the clinic for a physical examination. He states that he has not had a routine physical in 5 years. During the examination, the physician finds that digital rectal examination (DRE) reveals stoney hardening in the posterior lobe of the prostate gland that is not mobile. The nurse recognizes that the observation typically indicates what?
Correct Answer: C
Rationale: The correct answer is C: Evidence of a more advanced lesion. A stoney hardening in the posterior lobe of the prostate gland that is not mobile is indicative of a more advanced lesion, such as prostate cancer. This finding suggests that the lesion has progressed beyond the early stages. In early prostate cancer, the prostate gland may feel firm but not stoney hard, and the lesion is usually mobile. Metastatic disease would involve spread of the cancer to other parts of the body, which is not evident from the DRE alone. A normal finding would not present as stoney hardening and lack of mobility in the prostate gland during a DRE.
Question 4 of 9
The clinic nurse is caring for a patient whose grandmother and sister have both had breast cancer. She requested a screening test to determine her risk of developing breast cancer and it has come back positive. The patient asks you what she can do to help prevent breast cancer from occurring. What would be your best response?
Correct Answer: C
Rationale: The correct answer is C: Research has shown that exercising at least 30 minutes every day can reduce your chance of breast cancer. Rationale: 1. Regular exercise helps maintain a healthy weight, which is important in reducing the risk of breast cancer. 2. Physical activity can help regulate hormone levels, such as estrogen, which can affect breast cancer risk. 3. Exercise boosts the immune system and reduces inflammation, both of which play a role in cancer prevention. Summary: A: Eating a healthy diet is important, but it alone cannot provide all the protection needed against breast cancer. B: Tamoxifen may be recommended in some cases, but it is not the primary preventive measure for everyone. D: While genetic predisposition increases risk, lifestyle choices like exercise can still play a significant role in reducing the risk of breast cancer.
Question 5 of 9
The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively?
Correct Answer: B
Rationale: The correct answer is B. By asking the patient to demonstrate the instillation of medications, the nurse can directly assess the patient's ability to self-administer the medications safely and effectively. This method allows for a practical demonstration of skills, which is more reliable than relying solely on verbal descriptions or past experiences. Choices A, C, and D are incorrect because assessing for previous inability, describing the method, or evaluating functional status may not directly demonstrate the patient's competency in self-administering ocular medications.
Question 6 of 9
A nurse is assisting a patient in making dietarychoices that promote healthy bowel elimination. Which menu option should the nurse recommend?
Correct Answer: C
Rationale: The correct answer is C because it includes fiber-rich whole wheat bread, grapes, and walnuts which promote healthy bowel elimination. Whole wheat bread and fruits provide dietary fiber that aids in digestion and prevents constipation. Walnuts are high in omega-3 fatty acids which can also help with bowel regularity. Option A (Broccoli and cheese soup with potato bread) lacks fiber and may cause constipation due to the low fiber content. Option B (Turkey and mashed potatoes with brown gravy) may be low in fiber and high in fat, which can slow down digestion. Option D (Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing) is a healthier choice but may lack sufficient fiber for promoting healthy bowel elimination compared to option C.
Question 7 of 9
A patient with Parkinsons disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond?
Correct Answer: C
Rationale: The correct answer is C: Lets explore other options, because laxatives can have side effects and create dependency. The rationale for this is that while laxatives provide temporary relief for constipation, using them long-term can lead to dependency, electrolyte imbalances, and other side effects. The nurse should address the root cause of constipation and explore alternative strategies such as dietary changes, increased fluid intake, exercise, and bowel training. Choices A and B focus on supportive measures rather than addressing the issue of potential dependency on laxatives. Choice D suggests herbal remedies without considering the individual's specific condition and medical history.
Question 8 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 9 of 9
A nurse is using the explanatory model to determinethe etiology of an illness. Which questions should the nurse ask? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: What do you call your problem? In the explanatory model, this question helps the nurse understand the patient's perspective and cultural beliefs about their illness. By asking how the patient labels their illness, the nurse gains insight into the patient's understanding of the illness, which can influence their treatment adherence and outcomes. The other options are incorrect because: A: How should your sickness be treated? - This question focuses on treatment preferences rather than understanding the patient's beliefs. C: How does this illness work inside your body? - This question is more aligned with the biomedical model, seeking physiological explanations rather than patient perspectives. D: What do you fear most about your sickness? - While important for assessing emotional aspects, this question does not directly address the patient's explanatory model.