ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
A patient who was pregnant had a spontaneous abortion at approximately 4 weeks’ gestation. At the time of the miscarriage, it was thought that all products of conception were expelled. Two weeks later, the patient presents at the clinic office complaining of “crampy” abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/minute (bpm), and respirations, 20 breaths per minute. Based on this assessment data, what does the nurse anticipate as a clinical diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Uterine infection. The patient's symptoms of crampy abdominal pain, scant serosanguineous vaginal drainage with odor, negative pregnancy test, and vital signs indicating fever, low blood pressure, and irregular pulse suggest an infection. The history of recent miscarriage raises suspicion for retained products of conception leading to infection. Ectopic pregnancy (choice A) would present with different symptoms such as abdominal pain, vaginal bleeding, and positive pregnancy test. Gestational trophoblastic disease (choice C) typically presents with abnormal vaginal bleeding and high levels of hCG. Endometriosis (choice D) is a chronic condition and not related to the acute symptoms described. In summary, the clinical presentation aligns with uterine infection given the patient's history, symptoms, and vital signs.
Question 2 of 9
Which patient ismostat risk for increased peristalsis?
Correct Answer: B
Rationale: The correct answer is B. Stress, like having three final examinations on the same day, can lead to increased peristalsis due to the activation of the sympathetic nervous system. This can result in faster movement of food through the digestive system. The other choices are incorrect because: A - Ignoring the urge to defecate does not directly relate to increased peristalsis. C - Major depressive disorder is more likely to be associated with decreased peristalsis due to the effects of stress on the body. D - Elderly individuals tend to have reduced peristalsis due to age-related changes in the digestive system.
Question 3 of 9
The hospice nurse is caring for a 45-year-old mother of three young children in the patients home. During the most recent visit, the nurse has observed that the patient has a new onset of altered mental status, likely resulting from recently diagnosed brain metastases. What goal of nursing interventions should the nurse identify?
Correct Answer: D
Rationale: The correct answer is D. The goal of nursing interventions in this scenario is to teach family members how to interact with and ensure safety for the patient with impaired cognition. This is the most appropriate response because it addresses the immediate need to provide the patient with appropriate care and support in their home environment. By educating the family on how to interact with the patient and ensure their safety, the nurse can help maintain a sense of normalcy for the patient and promote their well-being. Choice A is incorrect because sedating the patient may not be the best approach without considering other interventions first. Choice B is incorrect as moving the patient to an acute-care facility may not be necessary or feasible at this time. Choice C is incorrect as it focuses on end-of-life care rather than addressing the immediate need of supporting the patient with altered mental status.
Question 4 of 9
A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear?
Correct Answer: B
Rationale: The correct answer is B: Pink. In a healthy ear, the tympanic membrane should appear pink due to the rich blood supply. This color indicates good vascularization and normal functioning of the ear. Yellowish-white (choice A), gray (choice C), and bluish-white (choice D) are incorrect because they do not reflect the normal color of a healthy tympanic membrane. Yellowish-white may indicate fluid behind the eardrum, gray may suggest infection or inflammation, and bluish-white could indicate poor blood flow or trauma. Therefore, the pink color of the tympanic membrane is the most appropriate and indicative of a healthy ear in this case.
Question 5 of 9
A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the management of the patients diarrhea?
Correct Answer: B
Rationale: The correct answer is B: Sandostatin. This drug is a somatostatin analog that can help manage HIV-related chronic severe diarrhea by reducing gastrointestinal secretions. Sandostatin works by inhibiting the release of various hormones and neurotransmitters in the gut, which can help control diarrhea in HIV patients. Rationale: A: Zithromax is an antibiotic that is not typically used to manage chronic severe diarrhea in HIV patients. C: Levaquin is also an antibiotic and not indicated for managing diarrhea in HIV patients. D: Biaxin is another antibiotic and not the appropriate choice for managing chronic severe diarrhea in HIV patients. In summary, Sandostatin is the correct choice as it specifically targets the underlying cause of diarrhea in HIV patients by reducing gastrointestinal secretions, whereas the other options are antibiotics that are not indicated for this purpose.
Question 6 of 9
In general, when a patient’s energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe?
Correct Answer: C
Rationale: The correct answer is C: Weight does not change. When a patient's energy requirements are completely met by kcal intake, their weight should remain stable as there is a balance between energy intake and expenditure. This indicates that the body is receiving adequate energy for its needs, leading to weight maintenance. A: Weight increases - This would indicate an excess of energy intake over expenditure, leading to weight gain. B: Weight decreases - This would indicate a deficit in energy intake compared to expenditure, resulting in weight loss. D: Weight fluctuates daily - Daily weight fluctuations are normal and can be influenced by factors like hydration levels, food intake, and exercise, but a stable weight over time indicates a balance between energy intake and expenditure.
Question 7 of 9
A 16-year-old female patient experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self-esteem. What action by the patient would best indicate that she is meeting the goal of improved body image and self-esteem?
Correct Answer: B
Rationale: The correct answer is B because discussing the future indicates acceptance and hope, a positive step towards improved body image and self-esteem. The patient is focusing on moving forward, which shows emotional growth and resilience. Choice A may provide temporary comfort but does not necessarily address underlying emotional issues. Choice C is related to pain management, not body image or self-esteem. Choice D suggests continued emotional distress rather than progress towards improved self-image.
Question 8 of 9
A nurse is a member of an interdisciplinary teamthat uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?
Correct Answer: C
Rationale: The correct answer is C: Document the variance in the patient’s record. By documenting the variance in the patient's record, the nurse can provide a clear record of the deviation from the critical pathway. This documentation is essential for tracking the patient's progress accurately and identifying potential issues that may require intervention. It allows for proper communication among the interdisciplinary team and ensures that everyone is aware of the deviation. Choice A is incorrect because adding data to the problem list may not provide a comprehensive record of the variance. Choice B is incorrect because focusing on charting using the DAR format does not address the deviation from the critical pathway. Choice D is incorrect because reporting a positive variance in the next team meeting may not accurately reflect the patient's actual progress and may lead to miscommunication within the team.
Question 9 of 9
The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, “How much fat should I have? I guess the less fat, the better.” Which information will the nurse include in the teaching session?
Correct Answer: D
Rationale: The correct answer is D: Deficiencies occur when fat intake falls below 10% of daily nutrition. Rationale: 1. Fat is essential for absorption of fat-soluble vitamins (A, D, E, K) and for maintaining healthy cell membranes. 2. Fat provides essential fatty acids (omega-3, omega-6) crucial for brain function and inflammation regulation. 3. Adequate fat intake prevents deficiencies like dry skin, poor wound healing, and hormonal imbalances. 4. A low-fat diet should still include at least 10% of daily nutrition from healthy fats for optimal health. Summary: A: Cholesterol intake is important but not the primary focus for a low-fat diet. B: Fats are significant for health, and extreme low-fat diets can lead to deficiencies. C: While some fats are from external sources, the body needs a minimum amount for proper functioning.