ATI RN
foundation of nursing questions and answers Questions
Question 1 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 2 of 9
In teaching mothers-to-be about infant nutrition, which instruction should the nurse provide?
Correct Answer: D
Rationale: The correct answer is D because breast milk or formula is recommended for the first 4 to 6 months as it provides essential nutrients for infant growth and development. Choosing A, B, or C is incorrect as they pose health risks to infants - corn syrup is not necessary, cow's milk is not suitable for infants, and honey can cause botulism in infants under 1 year old. Breast milk or formula is the safest and most nutritionally balanced option for infants in the first few months of life.
Question 3 of 9
A patient newly diagnosed with breast cancer states that her physician suspects regional lymph node involvement and told her that there are signs of metastatic disease. The nurse learns that the patient has been diagnosed with stage IV breast cancer. What is an implication of this diagnosis?
Correct Answer: A
Rationale: Rationale for Correct Answer A: Stage IV breast cancer indicates distant metastasis, making the patient ineligible for curative surgery. Treatment for stage IV focuses on palliative care to manage symptoms and improve quality of life. Summary of Other Choices: B: Stage IV breast cancer is not considered highly treatable as it has spread beyond the breast and nearby lymph nodes, making it more challenging to cure. C: There is no evidence to suggest that stage IV breast cancer will self-resolve. The prognosis for metastatic breast cancer is typically poor. D: The 5-year survival rate for stage IV breast cancer is generally lower than 15%, making this choice incorrect.
Question 4 of 9
Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient?
Correct Answer: C
Rationale: The correct answer is C: Reduce environmental noise and distractions before communicating. This intervention is most likely to facilitate effective communication with a hearing-impaired patient because it creates an optimal environment for the patient to better focus on the communication. By reducing noise and distractions, the patient can more easily concentrate on the conversation and lip reading, if needed. This approach demonstrates sensitivity to the patient's needs and enhances the chances of successful communication. The other choices are incorrect because: A: Asking the patient to repeat what was said may cause frustration and does not address the environmental factors that can hinder communication. B: Standing directly in front of the patient to facilitate lip reading may help, but it does not address the impact of environmental noise and distractions on communication. D: Raising the voice to project sound at a higher frequency is not effective as it can distort speech and may not necessarily improve understanding for a hearing-impaired patient.
Question 5 of 9
A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?
Correct Answer: A
Rationale: The correct initial action for the school nurse is to assess for signs and symptoms of anaphylaxis (Choice A). This is crucial as anaphylaxis is a severe allergic reaction that can be life-threatening and requires immediate intervention. Assessing for anaphylaxis symptoms such as difficulty breathing, swelling of the face or throat, and a rapid pulse helps the nurse quickly identify the severity of the situation. Administering OTC antihistamines (Choice C) or epinephrine (Choice D) should only be done after confirming the presence of anaphylaxis. Assessing for erythema and urticaria (Choice B) is important but not as immediate as assessing for signs of anaphylaxis in this scenario.
Question 6 of 9
The nurse learns about cultural issues involvedin the patient’s health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating?
Correct Answer: D
Rationale: The correct answer is D: Culturally congruent care. This concept refers to providing care that aligns with the patient's cultural beliefs and practices. By learning about cultural issues and enabling patients to receive care that is meaningful and supportive within their cultural context, the nurse is demonstrating culturally congruent care. A: Marginalized groups - This refers to groups in society who are disadvantaged and face discrimination. While understanding cultural issues may be important when caring for marginalized groups, it is not the main concept demonstrated in this scenario. B: Health care disparity - This refers to differences in access to healthcare and health outcomes among different populations. While cultural competence can help address healthcare disparities, it is not the concept being demonstrated here. C: Transcultural nursing - This refers to providing care across different cultures. While related, it does not specifically address the nurse's role in understanding and enabling culturally appropriate care for individual patients and families.
Question 7 of 9
During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?
Correct Answer: D
Rationale: The correct answer is D: Pneumocystis pneumonia. This is the most common life-threatening infection in HIV-positive patients with low CD4+ counts. Pneumocystis pneumonia is caused by the opportunistic pathogen Pneumocystis jirovecii, which can lead to severe respiratory distress and mortality in immunocompromised individuals. The other choices, A: Salmonella infection, B: Mycobacterium tuberculosis, and C: Clostridium difficile, can also cause infections in HIV-positive patients, but they are not as commonly associated with life-threatening complications in this population compared to Pneumocystis pneumonia. It is crucial for the nurse to prioritize assessment for signs and symptoms of Pneumocystis pneumonia in this patient to promptly intervene and prevent further complications.
Question 8 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 9 of 9
A nurse is using therapeutic communication witha patient. Which technique will the nurse use to ensure effective communication?
Correct Answer: A
Rationale: The correct answer is A because therapeutic communication focuses on building a trusting relationship and understanding the patient's feelings and needs. By changing negative self-talk to positive self-talk, the nurse can help the patient develop a more positive outlook and improve self-esteem. This technique promotes effective communication by creating a supportive and non-judgmental environment. Option B is incorrect because small group communication is not the primary focus of therapeutic communication. Option C is incorrect as electronic communication lacks the personal interaction needed for therapeutic communication. Option D is incorrect because intrapersonal communication involves self-reflection and is not directly related to building strong teams in the context of patient care.