ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Prone position post retinal detachment repair helps the gas bubble or silicone oil stay against the retina to support healing. 2. This position prevents the bubble/oil from moving and causing further detachment. 3. Repositioning can jeopardize the surgical repair and lead to complications. 4. Calling the physician (A) is unnecessary as the order is clear. 5. Instructing the patient to prevent bleeding (C) is not related to the positioning after retinal detachment repair. 6. Repositioning after the first dressing change (D) contradicts the initial order and risks complications.
Question 2 of 9
A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what?
Correct Answer: D
Rationale: The correct answer is D: The patient has been infected with HIV. Antibodies to the AIDS virus in the blood indicate a past or current infection with HIV. This is because the body produces antibodies in response to the presence of the virus. A: The patient is immune to HIV is incorrect because antibodies indicate exposure, not immunity. B: The patient's immune system is intact is incorrect because the presence of antibodies does not necessarily reflect the overall functionality of the immune system. C: The patient has AIDS-related complications is incorrect because the presence of antibodies does not directly indicate the presence of AIDS-related complications.
Question 3 of 9
A nurse is inserting an indwelling urinary catheterfor a male patient. Which action will the nurse take?
Correct Answer: D
Rationale: The correct answer is D because cleansing the meatus with circular strokes starting at the meatus and moving outward helps prevent the introduction of bacteria into the urethra. This technique minimizes the risk of urinary tract infections. Holding the shaft at a 60-degree angle (A) or with the dominant hand (B) is not necessary for catheter insertion. Cleansing the meatus 3 times with the same cotton ball (C) can introduce more bacteria and is not recommended.
Question 4 of 9
The nurse is caring for a patient who is to begin receiving external radiation for a malignant tumor of the neck. While providing patient education, what potential adverse effects should the nurse discuss with the patient?
Correct Answer: A
Rationale: The correct answer is A: Impaired nutritional status. Radiation therapy to the neck can lead to mucositis, dysphagia, and taste changes, which can impair the patient's ability to eat and maintain adequate nutrition. This can lead to weight loss, weakness, and delayed wound healing. Discussing this potential adverse effect with the patient is crucial for proactive management. Choice B: Cognitive changes, and Choice C: Diarrhea are less likely to be direct adverse effects of radiation therapy to the neck. Cognitive changes are more commonly associated with brain radiation, while diarrhea is a more common side effect of abdominal radiation. Choice D: Alopecia is a side effect of chemotherapy, not radiation therapy. Radiation therapy does not typically cause hair loss unless it is in the treatment field. Therefore, discussing alopecia with the patient receiving radiation for a malignant neck tumor is not a priority.
Question 5 of 9
Following a recent history of dyspareunia and lower abdominal pain, a patient has received a diagnosis of pelvic inflammatory disease (PID). When providing health education related to self-care, the nurse should address which of the following topics? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Use of condoms to prevent infecting others. This is important because PID is a sexually transmitted infection and using condoms can help prevent transmission to sexual partners. It is crucial to address this topic to ensure the patient understands the importance of safe sex practices. The other choices are incorrect: B: Appropriate use of antibiotics - While antibiotics are used to treat PID, this choice does not address self-care education for prevention. C: Taking measures to prevent pregnancy - While important for overall health, preventing pregnancy is not directly related to self-care for PID. D: The need for a Pap smear every 3 months - Pap smears are not directly related to PID management or prevention. E: The importance of weight loss in preventing symptoms - Weight loss is not a direct self-care measure for managing or preventing PID.
Question 6 of 9
When administering a patients eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal?
Correct Answer: C
Rationale: The correct answer is C: Occlude the puncta after applying the medication. By occluding the puncta after applying the eye drops, the nurse can prevent the medication from draining into the nasolacrimal duct and being absorbed systemically. This is important to ensure that the medication remains in the eye and exerts its intended local effect. Choice A (Ensure that the patient is well hydrated at all times) is incorrect because hydration status does not directly prevent absorption through the nasolacrimal duct. Choice B (Encourage self-administration of eye drops) is incorrect as the method of administration does not prevent absorption through the nasolacrimal duct. Choice D (Position the patient supine before administering eye drops) is incorrect as it does not address the specific issue of preventing absorption through the nasolacrimal duct.
Question 7 of 9
A 54-year-old has a diagnosis of breast cancer and is tearfully discussing her diagnosis with the nurse. The patient states, They tell me my cancer is malignant, while my coworkers breast tumor was benign. I just dont understand at all. When preparing a response to this patient, the nurse should be cognizant of what characteristic that distinguishes malignant cells from benign cells of the same tissue type?
Correct Answer: D
Rationale: The correct answer is D: Different molecular structure in the cells. Malignant cells have alterations in their molecular structure, leading to uncontrolled growth and invasion of surrounding tissues, while benign cells retain their normal molecular structure and do not invade nearby tissues. This distinction is crucial in understanding why malignant cells are cancerous and pose a greater risk compared to benign cells. Other choices are incorrect because: A: Slow rate of mitosis of cancer cells - Malignant cells actually have a rapid rate of mitosis, contributing to their uncontrolled growth. B: Different proteins in the cell membrane - While there may be differences in proteins, the molecular structure is a more fundamental difference between malignant and benign cells. C: Differing size of the cells - Cell size alone is not a definitive characteristic that distinguishes between malignant and benign cells; molecular structure plays a more significant role.
Question 8 of 9
A nurse has made a referral to a grief support group, knowing that many individuals find these both comforting and beneficial after the death of a loved one. What is the most important accomplishment available by attending a grief support group?
Correct Answer: D
Rationale: The correct answer is D: Normalization of feelings and experiences. Attending a grief support group helps individuals feel validated and understood by others who are going through similar emotions. This normalization can reduce feelings of isolation and provide a sense of belonging, which is crucial in the grieving process. It also allows individuals to recognize that their feelings and experiences are common reactions to loss. Choice A is incorrect because a grief support group focuses more on accepting and processing the new reality rather than incorporating the old life into it. Choice B is incorrect as it suggests maintaining the old life rather than adjusting to a new normal. Choice C is incorrect because the focus of a grief support group is not solely on social skills but on emotional support and coping mechanisms.
Question 9 of 9
A patient diagnosed with Bells palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles?
Correct Answer: A
Rationale: The correct answer is A: Blowing up balloons. Blowing up balloons involves the activation of the facial muscles, which helps prevent muscle atrophy in patients with Bell's palsy. This exercise promotes muscle strength and prevents weakness. Deliberately frowning (B), smiling repeatedly (C), and whistling (D) do not specifically target the facial muscles involved in Bell's palsy and may not be as effective in preventing muscle atrophy.