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
The nurse is caring for a patient has just been given a 6-month prognosis following a diagnosis of extensive stage small-cell lung cancer. The patient states that he would like to die at home, but the team believes that the patients care needs are unable to be met in a home environment. What might you suggest as an alternative?
Correct Answer: D
Rationale: The correct answer is D: Discuss a referral for hospice care. Hospice care provides specialized care for patients with terminal illnesses, focusing on comfort and quality of life. This option aligns with the patient's wish to die at home and ensures his care needs are met. Hospice care also provides emotional and spiritual support for both the patient and family. A: Discuss a referral for rehabilitation hospital - This option focuses on rehabilitation, which is not suitable for a patient with a terminal illness like extensive stage small-cell lung cancer. B: Panel the patient for a personal care home - Personal care homes may not provide the level of specialized care needed for a terminally ill patient. C: Discuss a referral for acute care - Acute care is more focused on treating acute illnesses and injuries, not providing end-of-life care for a patient with a terminal illness.
Question 3 of 9
The nurse is discussing the results of a patients diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss?
Correct Answer: C
Rationale: The correct answer is C because in sensorineural hearing loss, the sound is heard better in the ear with poorer hearing due to damage to the inner ear or auditory nerve. This is because the brain perceives the sound as louder in the affected ear to compensate for the hearing loss. Choice A is incorrect as it describes the result for conductive hearing loss. Choice B is incorrect as it indicates normal hearing. Choice D is incorrect as it describes the result for a lateralizing conductive hearing loss.
Question 4 of 9
A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will present with what alteration in laboratory values?
Correct Answer: A
Rationale: The correct answer is A: Increased eosinophils. Eosinophils are a type of white blood cell involved in allergic reactions. During anaphylaxis, the body releases chemicals that stimulate the production and activation of eosinophils, leading to an increase in their count. This helps in the identification of an allergic reaction. Incorrect Choices: B: Increased neutrophils - Neutrophils are not specific to allergic reactions and are typically increased in bacterial infections. C: Increased serum albumin - Serum albumin levels are not directly affected by allergic reactions. D: Decreased blood glucose - Hypoglycemia is not a typical manifestation of an allergic reaction.
Question 5 of 9
The nurses assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patients visual acuity?
Correct Answer: B
Rationale: The correct answer is B because the patient's inability to count fingers indicates severe visual impairment. Testing hand motion perception is a more appropriate initial assessment for patients with such significant visual losses. This method can differentiate between light perception and no light perception, providing valuable information about the patient's visual acuity. The other choices are incorrect because assessing vision using a Snellen chart (A) requires more visual acuity than just being able to see hand motion. Performing a detailed examination of external eye structures (C) and palpating periocular regions (D) are not relevant for assessing visual acuity and do not provide information on the patient's ability to perceive hand motion.
Question 6 of 9
On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Cholesteatoma. A red blemish behind the tympanic membrane is indicative of a cholesteatoma, which is a noncancerous cyst in the middle ear. This occurs due to the accumulation of skin cells and debris in the middle ear space. Other choices (A, C, D) are not associated with a red blemish on otoscopy. An acoustic tumor (A) typically presents as a slow-growing mass on the vestibulocochlear nerve. Facial nerve neuroma (C) involves the facial nerve and does not typically cause a red blemish. Glomus tympanicum (D) is a vascular tumor arising from the middle ear but does not usually present as a red blemish.
Question 7 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 8 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.
Question 9 of 9
Which instructions should thNe UnuRrsSe IinNclGudTeB w.hCenO tMeaching a pregnant patient with Class II heart disease?
Correct Answer: B
Rationale: The correct answer is B because pregnant patients with Class II heart disease should avoid strenuous activity to prevent further strain on the heart. Strenuous activity can increase the risk of complications in these patients. Option A is incorrect as excessive weight gain can exacerbate heart disease. Option C is incorrect because limiting fluid intake can lead to dehydration, which is harmful during pregnancy. Option D is incorrect as a diet high in calcium is not specifically indicated for pregnant patients with Class II heart disease.