ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
A patient is experiencing oliguria. Which actionshould the nurse performfirst?
Correct Answer: A
Rationale: The correct answer is A: Assess for bladder distention. Oliguria indicates decreased urine output, which could be due to urinary retention. Assessing for bladder distention helps identify the underlying cause. Requesting diuretics (B) without assessing first is premature. Increasing IV fluid rate (C) may worsen the situation if there is urinary retention. Encouraging caffeinated beverages (D) is not appropriate as they can worsen dehydration.
Question 2 of 9
The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient, what characteristic symptom would the nurse expect to find?
Correct Answer: A
Rationale: Step-by-step rationale for why A is correct: 1. Retinal detachment causes traction on the retina. 2. Traction on the retina can stimulate photoreceptors. 3. Stimulation of photoreceptors can lead to perception of flashing lights. 4. Therefore, the characteristic symptom of retinal detachment is flashing lights in the visual field. Summary: B: Sudden eye pain is not a characteristic symptom of retinal detachment. C: Loss of color vision is not typically associated with retinal detachment. D: Colored halos around lights are more indicative of conditions like glaucoma or corneal edema, not retinal detachment.
Question 3 of 9
A patient has sought care, stating that she developed hives overnight. The nurses inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed?
Correct Answer: A
Rationale: The correct answer is A: Type I hypersensitivity reaction. This type of reaction involves the release of histamine from mast cells and basophils, leading to symptoms like hives. It is characterized by the involvement of IgE antibodies. In this case, the patient developed hives quickly after exposure to the allergen, indicating an immediate hypersensitivity reaction typical of Type I. Choices B, C, and D are incorrect because they are associated with different mechanisms and timeframes of hypersensitivity reactions. Type II involves antibody-mediated cell destruction, Type III involves immune complex deposition, and Type IV is a delayed-type hypersensitivity reaction mediated by T cells, none of which are consistent with the rapid onset of hives seen in this patient.
Question 4 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 5 of 9
A patient is using laxatives three times dailyto lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient?
Correct Answer: A
Rationale: The correct answer is A. Long-term laxative use can lead to the bowel becoming less responsive to stimuli, resulting in constipation. This is due to the body becoming dependent on laxatives to stimulate bowel movements. Choice B is incorrect as laxatives typically do not cause trauma or scarring to the intestinal lining. Choice C is incorrect because while emollient laxatives can be helpful for constipation, long-term use is not recommended due to potential side effects. Choice D is incorrect because laxatives do not directly cause malnourishment or prevent waste production.
Question 6 of 9
A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss?
Correct Answer: C
Rationale: The correct answer is C: Whisper test. The nurse can perform a whisper test by whispering a series of numbers or words at a distance from the child to see if they can repeat them accurately. If the child struggles to hear and repeat the whispered words, it could indicate hearing loss. Rationale: A: Audiometry is a comprehensive hearing test that measures the range and sensitivity of hearing, not suitable for a quick preliminary assessment. B: Rinne test and D: Weber test are both tuning fork tests used to assess conductive and sensorineural hearing loss, not ideal for a quick initial screening of hearing loss. Summary: The Whisper test is the most suitable choice as it provides a quick and simple way to preliminarily assess hearing loss by evaluating the child's ability to hear and repeat whispered sounds accurately.
Question 7 of 9
A nurse needs to know how to find, evaluate, and use information effectively.
Correct Answer: C
Rationale: The correct answer is C: Clinical decision support system. A clinical decision support system is a type of system or design that helps healthcare professionals, including nurses, in making clinical decisions by providing them with relevant information and knowledge. This system assists in analyzing data to generate patient-specific recommendations or alerts to improve patient care. In the given scenario, the nurse's need to find, evaluate, and use information effectively aligns with the purpose of a clinical decision support system. This system enables the nurse to access evidence-based information, guidelines, and recommendations to enhance their decision-making process and improve patient outcomes. Summary of why other choices are incorrect: A: Computer competency does not equate to informatics competency. While computer skills are important, informatics involves a deeper understanding of using information effectively in practice. B: This choice provides a detailed explanation of informatics but does not directly address the type of system or design the nurse would be using to find, evaluate, and use information effectively. D: Nursing process
Question 8 of 9
A public health nurse is participating in a campaign aimed at preventing cervical cancer. What strategies should the nurse include is this campaign? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Promotion of HPV immunization. This strategy is effective in preventing cervical cancer by targeting the main cause, which is Human Papillomavirus (HPV). The HPV vaccine can protect against the most common types of HPV that cause cervical cancer. Encouraging young women to delay first intercourse (B) does not directly prevent HPV transmission, as the virus can be transmitted through other means. Smoking cessation (C) is important for overall health but does not specifically prevent cervical cancer. Vitamin D and calcium supplementation (D) may have general health benefits but do not directly prevent cervical cancer. Using safer sex practices (E) can reduce the risk of HPV transmission but does not provide the same level of protection as HPV immunization.
Question 9 of 9
In which situation would a dilation and curettage (D&C) be indicated?
Correct Answer: B
Rationale: The correct answer is B because an incomplete abortion at 16 weeks may require a D&C to remove remaining tissue to prevent infection and complications. Incomplete abortion means not all fetal tissue has been expelled, posing a risk. Choice A (complete abortion at 8 weeks) does not require a D&C as all tissue is expelled. Choice C (threatened abortion at 6 weeks) does not necessitate immediate intervention. Choice D (incomplete abortion at 10 weeks) is not the best choice as the risk of complications increases with gestational age.