ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
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 9
A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurses priority for care?
Correct Answer: B
Rationale: The correct answer is B: Protect the patient's airway. In anaphylaxis, airway compromise can lead to respiratory distress and even respiratory arrest. The priority is to ensure the patient has a patent airway to maintain oxygenation. This can be achieved through interventions such as positioning, oxygen therapy, and potentially intubation if needed. Monitoring the patient's level of consciousness (A) is important but secondary to ensuring airway patency. Providing psychosocial support (C) is not the immediate priority in anaphylaxis. Administering medications (D) is also important but only after ensuring the airway is protected.
Question 3 of 9
The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. With which tube will the nursemostlikely administer the feeding?
Correct Answer: B
Rationale: The correct answer is B: Jejunostomy tube. This tube is chosen because the patient has a history of aspiration pneumonia, which puts them at risk for aspiration if feeds are administered into the stomach. By administering feeds through a jejunostomy tube, the risk of aspiration pneumonia is minimized as the feed bypasses the stomach. Nasogastric tube (A) and Nasointestinal tube (C) would still deliver feeds to the stomach, increasing the risk of aspiration. PEG tube (D) is also not ideal as it delivers feeds directly to the stomach, which is not recommended for patients at risk for aspiration.
Question 4 of 9
A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking?
Correct Answer: A
Rationale: Step 1: The nurse is auditing and monitoring patients' health records, indicating a review process. Step 2: By reviewing patients' health records, the nurse is determining the degree to which standards of care are met. Step 3: This action aligns with auditing, which involves assessing if care meets established standards. Step 4: The other choices are incorrect because they do not directly involve auditing or monitoring for compliance with standards of care. Choice B talks about undocumented care, C about reimbursement, and D about treatment outcomes comparison.
Question 5 of 9
A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy?
Correct Answer: B
Rationale: The correct answer is B: Addressing possible barriers to adherence. This is crucial because adherence to the antiretroviral drug regimen is key for successful therapy in HIV patients. By identifying and addressing barriers such as medication side effects, cost, or forgetfulness, nurses can help patients stay on track with their treatment. Other choices are incorrect: A: Promoting complementary therapies is not the priority in initiating antiretroviral therapy. Adherence to the prescribed regimen is more critical. C: Educating about the pathophysiology of HIV is important, but it may not directly impact the success of the therapy as much as addressing adherence barriers. D: While follow-up blood work is necessary, it is not as immediate and impactful as addressing adherence barriers at the beginning of therapy.
Question 6 of 9
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 7 of 9
The nurse asks a patient where the pain is, andthe patient responds by pointing to the area of pain. Which form of communication did the patient use?
Correct Answer: B
Rationale: The correct answer is B: Nonverbal. The patient used nonverbal communication by pointing to the area of pain, which is a form of expressing information without words. This choice is correct because pointing is a nonverbal gesture that conveys a specific message. Verbal communication (A) involves spoken or written words, which were not used in this scenario. Intonation (C) refers to the rise and fall of the voice in speech, which was not demonstrated by the patient. Vocabulary (D) is the range of words known or used by a person, but the patient did not use words to communicate in this situation. In summary, the patient used nonverbal communication through pointing, making choice B the correct answer.
Question 8 of 9
A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B: Educational programs that focus on control and prevention. This intervention is the most crucial as it directly addresses the issue of the increasing incidence of HIV infection. By providing education on how to control and prevent the spread of HIV, the nurse can empower the community to take proactive measures to reduce transmission rates. A: Lifestyle actions that improve immune function may be helpful in general health promotion but do not directly target the prevention of HIV transmission. C: Appropriate use of standard precautions is important but is more focused on healthcare settings rather than community-wide prevention efforts. D: Screening programs for youth and young adults are valuable but may not be as effective as educational programs in preventing the spread of HIV.
Question 9 of 9
One aspect of the nurses comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would the nurse identify as a hope-fostering category?
Correct Answer: A
Rationale: The correct answer is A: Uplifting memories. When assessing hope in a terminally ill patient, identifying uplifting memories can foster hope by providing emotional support, positive experiences, and a sense of purpose. Memories can inspire optimism and comfort in difficult times. B: Ignoring negative outcomes is incorrect as it does not address the patient's emotional needs or promote coping strategies. C: Envisioning one specific outcome is incorrect because hope should encompass a range of possibilities, not just one specific outcome. D: Avoiding an actual or potential threat is incorrect as it focuses on avoidance rather than on promoting positive emotions and psychological well-being.