ATI RN
foundation of nursing practice questions Questions
Question 1 of 9
A patient has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurses most appropriate action?
Correct Answer: C
Rationale: The most appropriate action for the home health nurse to take in this situation where a patient reports distortions when looking at an Amsler grid is to arrange for the patient to be assessed for macular degeneration. Distortions in straight lines on an Amsler grid are a common early symptom of macular degeneration, a progressive eye condition that affects central vision. Macular degeneration is a leading cause of vision loss in older adults, making assessment and early intervention crucial in preserving vision. It is important for the nurse to take the patient's symptoms seriously and facilitate timely evaluation and management to prevent further vision loss. This would involve referring the patient to an ophthalmologist or an eye care specialist for a comprehensive evaluation and appropriate treatment.
Question 2 of 9
A patient who is scheduled for a skin test informs the nurse that he has been taking corticesteroids to help control his allergy symptoms. What nursing intervention should the nurse implement?
Correct Answer: A
Rationale: The patient should continue taking his corticosteroids regularly prior to testing. Corticosteroids can suppress the body's immune response and affect the results of skin tests by potentially causing a false-negative result. Instructing the patient to maintain his regular corticosteroid regimen will help ensure accurate testing results. It is essential to consult with the healthcare provider to determine the appropriate timing for testing in relation to corticosteroid use.
Question 3 of 9
Which routine nursing assessment is contraindicated for a patient admitted with suspected placenta previa?
Correct Answer: A
Rationale: Vaginal examination of the cervix may result in perforation of the placenta and subsequent hemorrhage in a patient admitted with suspected placenta previa. It is important to avoid any unnecessary manipulation of the cervix to prevent complications. Assessing cervical dilation and effacement should be avoided until placenta previa is ruled out to prevent harm to the patient.
Question 4 of 9
A nurse is teaching a group of women about the potential benefits of breast self-examination (BSE). The nurse should teach the women that effective BSE is dependent on what factor?
Correct Answer: A
Rationale: Effective breast self-examination (BSE) relies significantly on women's knowledge of their own breasts. Understanding how their breasts normally look and feel allows women to detect any changes such as lumps, dimpling, or discharge, which may be early signs of breast abnormalities like cancer. By being familiar with their breasts' normal appearance and texture, women can promptly seek medical attention if they notice any unusual changes. This self-awareness and familiarity with their breasts are crucial in enabling women to perform BSE effectively and to detect any potential issues early on.
Question 5 of 9
The nurse is planning the care of a patient who is adapting to the use of a hearing aid for the first time. What is the most significant challenge experienced by a patient with hearing loss who is adapting to using a hearing aid for the first time?
Correct Answer: B
Rationale: One of the most significant challenges experienced by patients with hearing loss who are adapting to using a hearing aid for the first time is learning to cope with the amplification of background noise. When a person starts using a hearing aid after experiencing hearing loss, they may find that the device picks up not only the sounds they want to hear but also surrounding noises, such as background chatter, traffic noise, or ambient sounds. This sudden increase in volume and clarity of background noise can be overwhelming and challenging for the individual to adjust to. It can affect their ability to focus on conversations or specific sounds they are trying to hear, leading to frustration and potentially causing them to avoid using the hearing aid altogether. Supporting the patient in gradually acclimating to these new sounds and providing strategies for managing background noise can help improve their overall experience with the hearing aid.
Question 6 of 9
While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?
Correct Answer: A
Rationale: Swelling and pain at the IV site can indicate extravasation, which is the leakage of a vesicant medication like doxorubicin hydrochloride into the surrounding tissues. It is crucial to stop the administration of the drug immediately upon suspicion of extravasation to minimize tissue damage and potential complications. By stopping the administration promptly, further harm can be prevented, and early interventions can be initiated to mitigate the effects of the extravasation. Notifications to the physician and appropriate actions, such as aspiration of any remaining drug, may follow after discontinuing the infusion.
Question 7 of 9
A nurse is examining a patient who has been diagnosed with a fibroadenoma. The nurse should recognize what implication of this patients diagnosis?
Correct Answer: B
Rationale: A fibroadenoma is a benign breast tumor commonly found in young women. In most cases, a fibroadenoma does not require radiation therapy. However, the patient might be referred for a biopsy to confirm the diagnosis and rule out any potential malignancy. While fibroadenomas can be related to hormonal changes in the body, they are not directly linked to the use of oral contraceptives. Recognizing this implication of the patient's diagnosis is essential for providing appropriate care and follow-up.
Question 8 of 9
While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurses most appropriate action?
Correct Answer: B
Rationale: The most appropriate action for the nurse to take when observing the surgical dressing saturated with serosanguineous drainage is to reinforce the dressing and reassess in 1 to 2 hours. Serosanguineous discharge is a common type of drainage following surgery, as it is a mixture of blood and serum. It is expected in the early stages of wound healing and does not necessarily indicate infection. By reinforcing the dressing and closely monitoring the drainage over the next couple of hours, the nurse can assess if the amount of drainage is decreasing or escalating. If there are any signs of infection, such as increasing redness, warmth, swelling, or excessive purulent discharge, then the nurse should notify the physician promptly. Until then, it is appropriate to continue observing and managing the drainage within the expected range.
Question 9 of 9
The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement?
Correct Answer: B
Rationale: After a mastoidectomy, the ear should be protected from water for several weeks. This is because exposing the area to water can increase the risk of infection. Keeping the ear dry allows the surgical site to heal properly and reduces the likelihood of postoperative complications such as infection. Therefore, instructing the patient to protect the ear from water is an important intervention to prevent postoperative infection following a mastoidectomy.