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
Which clinical intervention is the only known cure for preeclampsia?
Correct Answer: B
Rationale: The correct answer is B: Delivery of the fetus. The only known cure for preeclampsia is the delivery of the fetus, as this condition typically resolves after giving birth. Since preeclampsia can lead to serious complications for both the mother and baby, delivering the fetus is the most effective way to stop the progression of the condition. Magnesium sulfate (choice A) is used to prevent seizures in women with severe preeclampsia but does not cure the condition. Antihypertensive medications (choice C) are used to manage blood pressure in preeclampsia but do not cure it. Administration of aspirin (choice D) is used for prevention, not as a cure for preeclampsia.
Question 3 of 9
A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking?
Correct Answer: A
Rationale: Step 1: The nurse is auditing and monitoring patients' health records, indicating a review process. Step 2: By reviewing patients' health records, the nurse is determining the degree to which standards of care are met. Step 3: This action aligns with auditing, which involves assessing if care meets established standards. Step 4: The other choices are incorrect because they do not directly involve auditing or monitoring for compliance with standards of care. Choice B talks about undocumented care, C about reimbursement, and D about treatment outcomes comparison.
Question 4 of 9
A nurse is performing an assessment on a patientwho has not had a bowel movement in 3 days. The nurse will expect which other assessment finding?
Correct Answer: A
Rationale: The correct answer is A: Hypoactive bowel sounds. When a patient has not had a bowel movement in 3 days, it indicates constipation. Constipation can lead to decreased peristalsis, resulting in hypoactive bowel sounds. Increased fluid intake (B) would be a potential intervention, not an expected assessment finding. A soft tender abdomen (C) may indicate other issues like inflammation or infection, not directly related to constipation. Jaundice in the sclera (D) is indicative of liver dysfunction, not a typical finding associated with constipation.
Question 5 of 9
A hospital nurse has experienced percutaneous exposure to an HIV-positive patients blood as a result of a needlestick injury. The nurse has informed the supervisor and identified the patient. What action should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Report to the emergency department or employee health department. 1. Immediate action is crucial after exposure to HIV-positive blood. 2. Reporting to the emergency department or employee health department ensures prompt evaluation and appropriate management. 3. The supervisor should also be informed to initiate the necessary protocols. 4. The other choices are incorrect: - A: Chlorhexidine may not be sufficient for post-exposure prophylaxis. - C: Hydrocolloid dressing is not appropriate for managing needlestick injuries. - D: Following up with the primary care provider may cause delays in receiving timely post-exposure prophylaxis.
Question 6 of 9
Traditionally, nurses have been involved with tertiary cancer prevention. However, an increasing emphasis is being placed on both primary and secondary prevention. What would be an example of primary prevention?
Correct Answer: C
Rationale: The correct answer is C: Teaching patients to wear sunscreen, which is an example of primary prevention. Primary prevention aims to prevent the occurrence of a disease before it occurs by addressing risk factors. In this case, teaching patients to wear sunscreen helps prevent skin cancer by reducing exposure to harmful UV rays. Yearly Pap tests (A) are a secondary prevention measure for cervical cancer, detecting precancerous changes. Testicular self-examination (B) is a form of secondary prevention for testicular cancer, aiming to detect any abnormalities early. Screening mammograms (D) are also a secondary prevention measure for breast cancer, detecting tumors at an early stage.
Question 7 of 9
In providing diabetic teaching for a patient with type 1 diabetes mellitus, which instructions will the nurse provide to the patient?
Correct Answer: B
Rationale: The correct answer is B: Saturated fat should be limited to less than 7% of total calories. This is because limiting saturated fat intake is crucial in managing type 1 diabetes to reduce the risk of cardiovascular diseases. Saturated fats can worsen insulin resistance and lead to complications. Choice A is incorrect as diabetic management involves more than just insulin. Choice C is incorrect because nonnutritive sweeteners should be used in moderation due to potential side effects. Choice D is incorrect as individuals with diabetes should aim to keep cholesterol intake low to prevent heart problems.
Question 8 of 9
The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads in the electronic health record that the patient has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem?
Correct Answer: B
Rationale: The correct answer is B: Impaired wound healing. Radiation therapy can lead to damage to the skin and blood vessels, affecting wound healing. The nurse should prioritize assessing the patient's skin integrity and any signs of impaired wound healing to prevent complications post-surgery. A: Cognitive deficits - While radiation therapy can impact cognitive function in some cases, it is not the most immediate concern related to surgery post-radiation therapy. C: Cardiac tamponade - Although radiation therapy can increase the risk of heart-related issues, such as pericarditis, cardiac tamponade is a rare and acute complication that is not the most likely immediate concern post-radiation therapy. D: Tumor lysis syndrome - This syndrome is more commonly seen in patients undergoing chemotherapy rather than radiation therapy. It is not typically a concern immediately post-radiation therapy.
Question 9 of 9
While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patients health history is most likely to be linked to the patients hearing deficit?
Correct Answer: D
Rationale: The correct answer is D: Previous perforation of the eardrum. A perforated eardrum can lead to hearing loss as it affects the transmission of sound waves to the inner ear. This is the most likely link to the patient's hearing deficit as trauma or injury to the eardrum can directly impact hearing. Incorrect choices: A: Recent completion of radiation therapy for treatment of thyroid cancer - Radiation therapy for thyroid cancer typically does not directly affect hearing. B: Routine use of quinine for management of leg cramps - Quinine use is associated with tinnitus (ringing in the ears) but not typically with hearing loss. C: Allergy to hair coloring and hair spray - Allergy to hair products is not directly related to hearing loss. In summary, the most likely cause of the patient's hearing deficit based on the health history provided is the previous perforation of the eardrum, as it directly affects the transmission of sound waves to the inner ear.