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
The hospice nurse has just admitted a new patient to the program. What principle guides hospice care?
Correct Answer: A
Rationale: The correct answer is A because hospice care is centered on a holistic approach that considers the physical, emotional, social, and spiritual needs of both the patient and their family. This principle recognizes that caring for a terminally ill patient involves supporting the entire family unit. Choice B is incorrect because family support is integral to hospice care. Choice C is incorrect because hospice care extends beyond just the patient to include their loved ones. Choice D is incorrect because the care team should address all aspects of care for both the patient and their family, not prioritize one over the other.
Question 3 of 9
A patient has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray?
Correct Answer: A
Rationale: The correct answer is A because using clock cues helps the patient visualize the placement of items based on a familiar concept. This aids in compensating for the loss of vision after head trauma. Choice B does not provide specific guidance on how to describe the placement. Choice C may be confusing for the patient as it is not a common way to describe item placement. Choice D puts unnecessary burden on the patient to describe the location first before confirming, which may be challenging for someone with sudden loss of vision.
Question 4 of 9
A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what?
Correct Answer: D
Rationale: The correct answer is D: The patient has been infected with HIV. Antibodies to the AIDS virus in the blood indicate a past or current infection with HIV. This is because the body produces antibodies in response to the presence of the virus. A: The patient is immune to HIV is incorrect because antibodies indicate exposure, not immunity. B: The patient's immune system is intact is incorrect because the presence of antibodies does not necessarily reflect the overall functionality of the immune system. C: The patient has AIDS-related complications is incorrect because the presence of antibodies does not directly indicate the presence of AIDS-related complications.
Question 5 of 9
A patient has just been diagnosed with prostate cancer and is scheduled for brachytherapy next week. The patient and his wife are unsure of having the procedure because their daughter is 3 months pregnant. What is the most appropriate teaching the nurse should provide to this family?
Correct Answer: B
Rationale: The correct answer is B because brachytherapy does not pose a risk to the patient's daughter or her unborn child. Brachytherapy involves placing radioactive sources inside or near the tumor, which does not make the patient radioactive. The radiation does not travel far and does not pose a risk to others. Therefore, the daughter and her infant are safe from any radiation exposure. Choices A, C, and D are incorrect because there is no need for the patient to avoid contact with the baby after delivery, the brachytherapy is not contraindicated for safety reasons, and there is no requirement for the patient to avoid close contact with his daughter for 2 months.
Question 6 of 9
A nurse is pouching an ostomy on a patient withan ileostomy. Which action by the nurse ismostappropriate?
Correct Answer: B
Rationale: The correct answer is B, emptying the pouch if it is more than one-third to one-half full. This action is appropriate to prevent leakage and skin irritation. When the pouch becomes too full, it can put pressure on the seal, leading to potential leaks. Emptying the pouch at one-third to one-half fullness helps maintain a secure seal and prevents skin breakdown. Choice A is incorrect because changing the skin barrier portion of the ostomy pouch daily is unnecessary and can lead to skin irritation and breakdown. Choice C is incorrect because cleansing the skin around the stoma with soap and water excessively can strip the skin of its natural oils and cause irritation. Choice D is incorrect because leaving a 1/2-inch space around the stoma when measuring for the barrier device may result in an improper fit, leading to leakage and skin issues.
Question 7 of 9
A nurse is using therapeutic communication witha patient. Which technique will the nurse use to ensure effective communication?
Correct Answer: A
Rationale: The correct answer is A because therapeutic communication focuses on building a trusting relationship and understanding the patient's feelings and needs. By changing negative self-talk to positive self-talk, the nurse can help the patient develop a more positive outlook and improve self-esteem. This technique promotes effective communication by creating a supportive and non-judgmental environment. Option B is incorrect because small group communication is not the primary focus of therapeutic communication. Option C is incorrect as electronic communication lacks the personal interaction needed for therapeutic communication. Option D is incorrect because intrapersonal communication involves self-reflection and is not directly related to building strong teams in the context of patient care.
Question 8 of 9
A patient is being discharged home from the ambulatory surgery center after an incisional biopsy of a mass in her left breast. What are the criteria for discharging this patient home? Select all that apply.
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct: 1. Ambulating is a crucial postoperative activity to prevent complications like blood clots. 2. Understanding when to ambulate ensures the patient follows proper recovery guidelines. 3. Proper ambulation aids in preventing postoperative complications and promotes healing. Summary of why other choices are incorrect: B. Having someone accompany the patient is important for support but not a strict criteria for discharge. C. While understanding activity restrictions is important, it is not a specific criteria for immediate discharge. D. Understanding care for the biopsy site is essential but not a strict criteria for immediate discharge. E. Removal of a urinary catheter is not typically related to discharge criteria for a breast biopsy.
Question 9 of 9
You are caring for a patient who has just been told that her stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the patient the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer?
Correct Answer: A
Rationale: The correct answer is A: Palliative surgery. In this scenario, the patient's colon cancer has already progressed to stage IV with metastasis to the liver, indicating an advanced and incurable condition. Palliative surgery aims to alleviate symptoms, improve quality of life, and prolong survival without aiming for a cure. Reconstructive surgery (B) is typically done to restore form or function, which is not the primary goal in this case. Salvage surgery (C) is usually performed to rescue a situation where initial treatment has failed, which is not the case here. Prophylactic surgery (D) is preventive and is not appropriate in a situation where cancer is already present and advanced.