ATI RN
foundations of nursing practice questions Questions
Question 1 of 5
A patient has been diagnosed with endometriosis. When planning this patients care, the nurse should prioritize what nursing diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Acute pain related to misplaced endometrial tissue. This nursing diagnosis should be prioritized because endometriosis commonly presents with severe pelvic pain. Managing pain is crucial for the patient's comfort and quality of life. Anxiety (choice A) is not the priority as pain management takes precedence. Ineffective tissue perfusion (choice C) is not a priority unless the patient is actively hemorrhaging. Excess fluid volume (choice D) is not typically associated with endometriosis. Prioritizing pain management will address the immediate and most distressing symptom for the patient.
Question 2 of 5
The nurse is caring for a 63-year-old patient with ovarian cancer. The patient is to receive chemotherapy consisting of Taxol and Paraplatin. For what adverse effect of this treatment should the nurse monitor the patient?
Correct Answer: A
Rationale: The correct answer is A: Leukopenia. Taxol and Paraplatin are known to cause bone marrow suppression, leading to decreased white blood cell counts. Leukopenia can increase the patient's risk of infection, so monitoring for signs of infection is crucial. Metabolic acidosis, hyperphosphatemia, and respiratory alkalosis are not typically associated with Taxol and Paraplatin chemotherapy.
Question 3 of 5
The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?
Correct Answer: A
Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely
Question 4 of 5
A patient who came to the clinic after finding a mass in her breast is scheduled for a diagnostic breast biopsy. During the nurses admission assessment, the nurse observes that the patient is distracted and tense. What is it important for the nurse to do?
Correct Answer: A
Rationale: The correct answer is A because acknowledging the patient's fear validates their emotions, builds trust, and shows empathy. This can help the patient feel understood and supported during a vulnerable time. Choice B is incorrect because discussing support groups may not address the patient's immediate emotional needs. Choice C is incorrect because assessing stress management skills may not be the priority at this moment when the patient is visibly tense. Choice D is incorrect because documenting a nursing diagnosis should come after addressing the patient's immediate emotional state.
Question 5 of 5
A new mother who is breastfeeding calls the clinic to speak to a nurse. The patient is complaining of pain in her left breast and describes her breast as feeling doughy. The nurse tells her to come into the clinic and be checked. The patient is diagnosed with acute mastitis and placed on antibiotics. What comfort measure should the nurse recommend?
Correct Answer: D
Rationale: The correct answer is D: Perform gentle massage to stimulate neutrophil migration. Gentle massage helps to promote drainage of the infected area by stimulating neutrophil migration, which aids in fighting the infection. This can help alleviate the pain and discomfort associated with acute mastitis. Cold compresses (choice A) may provide some relief, but they do not address the underlying issue of promoting neutrophil migration. Avoiding washing the breasts (choice C) is not recommended as maintaining good hygiene is important in preventing further infections. Avoiding wearing a bra (choice B) may not directly address the infection and may not be practical for the patient's daily activities.