ATI RN
foundation of nursing practice questions Questions
Question 1 of 9
A patient is post-operative day 1 following a vaginal hysterectomy. The nurse notes an increase in the patients abdominal girth and the patient complains of bloating. What is the nurses most appropriate action?
Correct Answer: B
Rationale: The most appropriate action for the nurse to take in this situation is to apply warm compresses to the patient's lower abdomen. Abdominal bloating and an increase in abdominal girth can be common following a vaginal hysterectomy. Applying warm compresses to the lower abdomen can help to relieve bloating and discomfort by promoting relaxation of the abdominal muscles and increasing blood flow to the area. This can provide relief to the patient and support their recovery process. Applying warm compresses is a non-invasive intervention that can be easily implemented and is commonly used in post-operative care to address abdominal discomfort.
Question 2 of 9
The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
Correct Answer: B
Rationale: The signs of magnesium toxicity that the nurse should monitor for in a patient with severe preeclampsia on IV magnesium sulfate include an altered sensorium (confusion, lethargy, slurred speech) and a respiratory rate of less than 12 breaths per minute. Altered sensorium is a common symptom of magnesium toxicity, reflecting the drug's central nervous system depressant effects. A decreased respiratory rate can indicate respiratory depression, a potentially serious complication of magnesium toxicity. Monitoring for these signs is crucial to promptly identifying and managing magnesium toxicity in patients on magnesium sulfate therapy. Signs such as cool, clammy skin and a pulse oximeter reading of 95% would not be indicative of magnesium toxicity.
Question 3 of 9
For the patient who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to
Correct Answer: A
Rationale: Rho(D) immune globulin (RhoGAM) needs to be administered within 72 hours postpartum to Rh-negative patients who have given birth to Rh-positive infants to prevent Rh sensitization. The patient delivered at 6:30 AM on January 10, so the RhoGAM should be administered prior to that time on January 13, which is 72 hours postpartum. Therefore, the correct choice is A. 6:30 AM on January 10.
Question 4 of 9
The public health nurse is presenting a health-promotion class to a group at a local community center. Which intervention most directly addresses the leading cause of cancer deaths in North America?
Correct Answer: B
Rationale: Smoking cessation most directly addresses the leading cause of cancer deaths in North America, which is lung cancer. Tobacco use, particularly cigarette smoking, is the primary cause of lung cancer. By helping individuals quit smoking, the public health nurse is targeting the main risk factor for lung cancer and therefore addressing the root cause of the issue. This intervention has the potential to have a significant impact on reducing cancer-related deaths in the community. Monthly self-breast exams, annual colonoscopies, and monthly testicular exams are important for detecting breast, colon, and testicular cancers respectively, but they do not directly address the leading cause of cancer deaths in North America.
Question 5 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 6 of 9
A nurse is explaining to the nursing students working on the antepartum unit how to assess for edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area? N R I G B.C M U S N T O
Correct Answer: C
Rationale: Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as +1 indicates minimal edema of the lower extremities. Marked edema of the lower extremities is +2 edema. Generalized massive edema (+4) includes the accumulation of fluid in the peritoneal cavity.
Question 7 of 9
A nurse is providing discharge teaching for apatient who is going home with a guaiac test. Which statement by the patient indicates the need for further education?
Correct Answer: A
Rationale: The statement "If I get a blue color that means the test is negative" given by the patient indicates the need for further education. This is incorrect information because a blue color in the guaiac test indicates a positive result, which means the presence of fecal occult blood. The patient should be taught that a positive result indicates the need for further evaluation and follow-up with their healthcare provider. Proper understanding of the test results is vital to ensure accurate interpretation and appropriate management. Further clarification and education are necessary to correct this misconception and guide the patient towards understanding the significance of a positive result.
Question 8 of 9
A female patient tells the nurse that she thinks she has a vaginal infection because she has noted inflammation of her vulva and the presence of a frothy, yellow-green discharge. The nurse recognizes that the clinical manifestations described are typical of what vaginal infection?
Correct Answer: A
Rationale: The clinical manifestations of inflammation of the vulva and the presence of frothy, yellow-green discharge are indicative of a vaginal infection caused by Trichomonas vaginalis. Trichomoniasis is a sexually transmitted infection caused by a protozoan parasite. It commonly presents with symptoms such as frothy, yellow-green vaginal discharge, vaginal itching, inflammation of the vulva, and sometimes a foul odor. Testing for Trichomonas vaginalis can be done through microscopic examination of the vaginal discharge or through nucleic acid amplification tests. Treatment usually involves the use of antibiotics such as metronidazole or tinidazole. It is important to promptly diagnose and treat trichomoniasis to prevent complications and further transmission.
Question 9 of 9
An oncology patient will begin a course of chemotherapy and radiation therapy for the treatment of bone metastases. What is one means by which malignant disease processes transfer cells from one place to another?
Correct Answer: D
Rationale: Malignant disease processes transfer cells from one place to another primarily through the invasion of healthy host tissues. Cancer cells have the ability to break away from the primary tumor site and invade nearby healthy tissues. Once invasive cancer cells find their way into blood vessels or lymphatics, they can be carried to distant sites in the body where they can form new tumors, establish metastases, and spread the disease. This invasive property of cancer cells underlies the ability of cancer to spread throughout the body, a process known as metastasis. Commanding the cells to appear to adhere to primary tumor cells, inducing mutation of cells of another organ, or phagocytizing healthy cells are not mechanisms by which malignant disease processes transfer cells from one place to another.