ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
A patient who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The labor and birth nurse performs the NfollRowiIng aGssesBsm.eCntsM. The vaginal exam is deferred until the U S N T O physician is in attendance. The patient is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The patient is then transferred to the antepartum unit for continued observation. Several hours later, the patient complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The patient is placed on the EFM and no fetal heart tones are observed. What does the nurse suspect is occurring?
Correct Answer: D
Rationale: The correct answer is D: Hidden placental abruption. In this scenario, the patient had PROM and is now presenting with decreased fetal movement and absence of fetal heart tones after a fundal height increase. These signs suggest a hidden placental abruption, where the placenta has partially detached, leading to fetal distress and potential fetal demise. The absence of contractions rules out active labor (B) as the cause. Placental previa (A) would typically present with painless vaginal bleeding, which is not described in the scenario. Placental abruption (C) usually presents with painful vaginal bleeding, which is also not mentioned. Therefore, the most likely explanation for the symptoms described is a hidden placental abruption.
Question 2 of 9
A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurses priority for care?
Correct Answer: B
Rationale: The correct answer is B: Protect the patient's airway. In anaphylaxis, airway compromise can lead to respiratory distress and even respiratory arrest. The priority is to ensure the patient has a patent airway to maintain oxygenation. This can be achieved through interventions such as positioning, oxygen therapy, and potentially intubation if needed. Monitoring the patient's level of consciousness (A) is important but secondary to ensuring airway patency. Providing psychosocial support (C) is not the immediate priority in anaphylaxis. Administering medications (D) is also important but only after ensuring the airway is protected.
Question 3 of 9
Which action indicates the nurse is meeting aprimary goal of cultural competent care for patients?
Correct Answer: C
Rationale: The correct answer is C because providing individualized care is a fundamental aspect of cultural competence. This means tailoring care to meet the unique cultural, social, and personal needs of each patient. It involves understanding and respecting a patient's beliefs, values, and practices. Explanation: A. Providing care to transgender patients is important, but it is not the primary goal of cultural competence. B. Restoring relationships is beneficial but may not directly address cultural competence. D. Providing care to surgical patients is a common nursing duty but does not specifically relate to cultural competence.
Question 4 of 9
A patient has just returned to the unit from the PACU after surgery for a tumor within the spine. The patient complains of pain. When positioning the patient for comfort and to reduce injury to the surgical site, the nurse will position to patient in what position?
Correct Answer: B
Rationale: The correct answer is B: In a flat side-lying position. Rationale: 1. A flat side-lying position helps reduce pressure on the surgical site, promoting comfort and preventing injury. 2. This position minimizes strain on the spine and supports proper alignment. 3. High Fowlers position may increase pressure on the surgical area due to increased intra-abdominal pressure. 4. Trendelenberg position and reverse Trendelenberg position are not appropriate for spine surgery patients as they can cause increased blood flow to the surgical site, leading to potential complications.
Question 5 of 9
As a staff member in a local hospice, a nurse deals with death and dying on a frequent basis. Where would be the safe venue for the nurse to express her feelings of frustration and grief about a patient who has recently died?
Correct Answer: D
Rationale: The correct answer is D: At a memorial service. This is a safe venue for the nurse to express her feelings of frustration and grief about a patient who has recently died because a memorial service is specifically designed to honor and remember the deceased. It provides a supportive and understanding environment where emotions can be shared openly without judgment. The nurse can find comfort in sharing her feelings with others who have also been impacted by the patient's passing. Incorrect choices: A: In the cafeteria - Not an appropriate setting for expressing personal emotions related to death and dying. B: At a staff meeting - Might not be the most suitable place as the focus is on work-related matters. C: At a social gathering - Not specifically designed for processing grief and may not provide the necessary support and understanding.
Question 6 of 9
A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy?
Correct Answer: B
Rationale: The correct answer is B: Addressing possible barriers to adherence. This is crucial because adherence to the antiretroviral drug regimen is key for successful therapy in HIV patients. By identifying and addressing barriers such as medication side effects, cost, or forgetfulness, nurses can help patients stay on track with their treatment. Other choices are incorrect: A: Promoting complementary therapies is not the priority in initiating antiretroviral therapy. Adherence to the prescribed regimen is more critical. C: Educating about the pathophysiology of HIV is important, but it may not directly impact the success of the therapy as much as addressing adherence barriers. D: While follow-up blood work is necessary, it is not as immediate and impactful as addressing adherence barriers at the beginning of therapy.
Question 7 of 9
The nurse is developing a plan of care for a patient newly diagnosed with Bells palsy. The nurses plan of care should address what characteristic manifestation of this disease?
Correct Answer: B
Rationale: The correct answer is B: Facial paralysis. Bell's palsy is characterized by sudden, temporary weakness or paralysis of the facial muscles on one side of the face. This manifests as drooping of the eyelid and corner of the mouth, difficulty smiling or closing the eye. Tinnitus (A) is ringing in the ears, not a common symptom of Bell's palsy. Pain at the base of the tongue (C) is not a typical manifestation of Bell's palsy. Diplopia (D) is double vision, which is not a primary symptom of Bell's palsy. Therefore, the correct manifestation to address in the plan of care for a patient with Bell's palsy is facial paralysis.
Question 8 of 9
The nurse is providing preoperative education for a patient diagnosed with endometriosis. A hysterectomy has been scheduled. What education topic should the nurse be sure to include for this patient?
Correct Answer: D
Rationale: The correct answer is D because it addresses a crucial aspect of preoperative care for a patient undergoing a hysterectomy due to endometriosis. Emptying the bladder before surgery helps prevent urinary retention postoperatively. Placing a catheter during surgery ensures proper drainage and prevents bladder distention. This education topic is essential for the patient's comfort and well-being during and after the procedure. Choices A, B, and C are incorrect: A: Menstrual periods will not continue after a hysterectomy as the uterus is removed. B: Normal activity is usually restricted after a hysterectomy to promote healing. C: Hormone levels are affected after a hysterectomy, especially if the ovaries are also removed.
Question 9 of 9
A patient is to undergo an ultrasound-guided core biopsy. The patient tells the nurse that a friend of hers had a stereotactic core biopsy. She wants to understand the differences between the two procedures.What would be the nurses best response?
Correct Answer: A
Rationale: The correct answer is A because an ultrasound-guided core biopsy is indeed faster, less expensive, and does not use radiation. - "Faster": Ultrasound-guided biopsies are typically quicker compared to stereotactic biopsies, as they are performed in real-time using ultrasound imaging. - "Less expensive": Ultrasound-guided biopsies are generally more cost-effective than stereotactic biopsies due to the equipment and resources required. - "Does not use radiation": Unlike stereotactic biopsies which involve the use of X-rays for guidance, ultrasound-guided biopsies do not expose the patient to radiation, making them safer in that aspect. The other choices are incorrect because they either inaccurately state that ultrasound-guided biopsies use radiation (C), take more time (D), or imply a slight increase in cost without highlighting the key advantages of speed and lack of radiation (B).