ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient?
Correct Answer: D
Rationale: The correct answer is D: Obtain a stool culture to identify possible pathogens. This is the most appropriate nursing intervention because chronic diarrhea in a patient with AIDS can be caused by various pathogens such as parasites, bacteria, or viruses. By obtaining a stool culture, the healthcare team can identify the specific pathogen responsible for the diarrhea and initiate targeted treatment. A: Positioning the patient in the high Fowler's position is not directly related to addressing the underlying cause of chronic diarrhea in this patient. B: Temporarily eliminating animal protein from the patient's diet may not be necessary or effective in treating chronic diarrhea without knowing the specific cause identified through stool culture. C: Making sure the patient eats raw fruit is not recommended as raw fruits can sometimes worsen diarrhea due to their high fiber content and potential for carrying pathogens. In summary, obtaining a stool culture is the most appropriate intervention as it helps identify the specific pathogen causing the diarrhea, while the other options do not directly address the underlying cause.
Question 2 of 9
A patient with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the patient?
Correct Answer: A
Rationale: The correct answer is A: Sit or stand in front of the patient when speaking. This choice is correct because it allows the patient with otosclerosis to directly see the nurse's face and lip movements, aiding in lip-reading and understanding speech. Sitting or standing in front of the patient also ensures better eye contact and reduces background noise interference. Choice B is incorrect because exaggerated lip and mouth movements may distort speech and make it harder for the patient to understand. Choice C is incorrect because standing in front of a light or window can create glare and make it difficult for the patient to see the nurse's face clearly. Choice D is incorrect because saying the patient's name loudly before starting to talk does not directly address the communication needs of a patient with otosclerosis.
Question 3 of 9
The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse’s next action?
Correct Answer: D
Rationale: The correct answer is D: Use electronic fetal surveillance to determine a baseline fetal heart rate. This is important in assessing the well-being of the fetus during labor, especially in the presence of genital herpes lesions. Monitoring the fetal heart rate helps in detecting any signs of distress or compromise due to maternal infection. A: Asking about the patient's last intake is important but not the immediate priority when managing a patient with active genital herpes lesions in labor. B: Taking a culture of the lesions might be helpful but not the immediate action needed in this situation. C: Asking about unprotected sex is relevant but not as critical as monitoring the fetal well-being during labor in this scenario. Overall, the most critical action is to monitor the fetal heart rate for any signs of distress related to the maternal herpes infection.
Question 4 of 9
A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition?
Correct Answer: C
Rationale: The correct answer is C: Impaired verbal communication. In ALS, motor neurons deteriorate leading to muscle weakness and atrophy, including those involved in speech production. This results in impaired verbal communication. Chronic confusion (A) is not a common manifestation of ALS. Impaired urinary elimination (B) and bowel incontinence (D) are not typically associated with ALS, as it primarily affects motor neurons, not autonomic functions.
Question 5 of 9
A nurse is teaching the staff about health carereimbursement. Which information should the nurse include in the teaching session?
Correct Answer: A
Rationale: The correct answer is A because documentation by nurses in various settings like home health, long-term care, and hospitals impacts reimbursement. Proper documentation ensures services provided are accurately reflected, influencing reimbursement. Choice B is incorrect as it refers to Meaningful Use requirements for EHRs, not reimbursement. Choice C is incorrect as a "near miss" relates to patient safety, not reimbursement. Choice D is incorrect because HIPAA focuses on privacy and security of patient information, not reimbursement.
Question 6 of 9
A patient is being discharged home from the ambulatory surgery center after an incisional biopsy of a mass in her left breast. What are the criteria for discharging this patient home? Select all that apply.
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct: 1. Ambulating is a crucial postoperative activity to prevent complications like blood clots. 2. Understanding when to ambulate ensures the patient follows proper recovery guidelines. 3. Proper ambulation aids in preventing postoperative complications and promotes healing. Summary of why other choices are incorrect: B. Having someone accompany the patient is important for support but not a strict criteria for discharge. C. While understanding activity restrictions is important, it is not a specific criteria for immediate discharge. D. Understanding care for the biopsy site is essential but not a strict criteria for immediate discharge. E. Removal of a urinary catheter is not typically related to discharge criteria for a breast biopsy.
Question 7 of 9
The nurse is caring for patients with ostomies.In which ostomy location will the nurse expect very liquid stool to be present?
Correct Answer: C
Rationale: The correct answer is C: Ascending. Stool consistency varies based on the location of the ostomy. The ascending colon is responsible for absorbing water from stool, so an ostomy in this location will have very liquid stool. Sigmoid, transverse, and descending colons are responsible for further solidifying stool, so ostomies in those locations would not typically have very liquid stool.
Question 8 of 9
Which intrapartal assessment should be avoided when caring for a patient with HELLP syndrome?
Correct Answer: A
Rationale: The correct answer is A: Abdominal palpation. Palpating the abdomen can potentially cause rupture of the liver in patients with HELLP syndrome due to increased risk of liver hematoma. This can lead to severe bleeding and compromise the patient's condition. Checking deep tendon reflexes (C), auscultation of the heart and lungs (D), and venous sample of blood (B) are safe assessments that do not pose a risk of exacerbating the patient's condition. It is crucial to prioritize patient safety and avoid interventions that can harm the patient, making avoiding abdominal palpation the correct choice in caring for a patient with HELLP syndrome.
Question 9 of 9
A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patients care, the nurse should be aware that the effects of the tumor will primarily depend on what variable?
Correct Answer: B
Rationale: The correct answer is B: The specific hormones secreted by the tumor. Pituitary adenomas are known to secrete hormones that can lead to various endocrine disorders. Understanding the specific hormones secreted by the tumor is crucial in determining the clinical manifestations and planning appropriate treatment. Choices A, C, and D are incorrect because the primary determinant of the effects of the tumor in this case is the hormonal activity rather than whether the tumor uses aerobic or anaerobic respiration, the patient's pre-existing health status, or whether the tumor is primary or metastatic.