ATI RN
foundations of nursing test bank Questions
Question 1 of 9
A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care?
Correct Answer: A
Rationale: The correct answer is A: Assessing for mouth droop and decreased lateral eye gaze. After a radical mastoidectomy, the nurse should prioritize assessing for signs of facial nerve damage, such as mouth droop and decreased lateral eye gaze, which can indicate injury to the facial nerve during surgery. This is crucial as immediate intervention may be needed to prevent long-term complications. Choices B, C, and D are incorrect: B: Assessing for increased middle ear pressure and perforated ear drum is not the priority postoperative care for a radical mastoidectomy patient. C: Assessing for gradual onset of conductive hearing loss and nystagmus is not the priority as these are not immediate concerns postoperatively. D: Assessing for scar tissue and cerumen obstructing the auditory canal is not the priority as these are not immediate postoperative complications that require urgent attention.
Question 2 of 9
To decrease glandular cellular activity and prostate size, an 83-year-old patient has been prescribed finasteride (Proscar). When performing patient education with this patient, the nurse should be sure to tell the patient what?
Correct Answer: A
Rationale: Step 1: Finasteride is a medication that works by decreasing glandular cellular activity and reducing prostate size. Step 2: Dietary supplements can interact with finasteride, potentially affecting its effectiveness or causing adverse effects. Step 3: Reporting the planned use of dietary supplements to the physician ensures proper monitoring and adjustment of the treatment plan. Step 4: This communication promotes patient safety and optimal therapeutic outcomes. Therefore, choice A is correct as it emphasizes the importance of informing the physician about dietary supplement use to ensure the efficacy and safety of finasteride. Choices B, C, and D are incorrect as they do not directly relate to the mechanism of action or specific considerations of finasteride therapy.
Question 3 of 9
A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient?
Correct Answer: B
Rationale: The correct answer is B because hearing loss and tinnitus caused by aspirin are typically irreversible. Aspirin is known to cause ototoxicity, which can lead to permanent damage to the auditory system. The nurse should inform the patient that the hearing loss and tinnitus may not improve even after discontinuing aspirin. Choice A is incorrect because hearing loss caused by aspirin is usually permanent. Choice C is incorrect because aspirin is a known cause of tinnitus and hearing loss. Choice D is incorrect because tolerance to aspirin does not prevent or reverse ototoxic effects like tinnitus and hearing loss.
Question 4 of 9
During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?
Correct Answer: D
Rationale: The correct answer is D. The nurse should arrange for a referral to a rehabilitation facility for vision training. This option directly addresses the patient's inability to read medication bottles accurately due to a vision problem. Vision training can help improve the patient's ability to manage medication independently. A: Asking the social worker to investigate alternative housing arrangements is not relevant to the patient's vision problem affecting medication management. B: Asking the social worker to investigate community support agencies may not directly address the patient's vision issue and medication management. C: Encouraging the patient to explore surgical corrections for the vision problem is not appropriate without considering less invasive options first, such as vision training.
Question 5 of 9
The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do?
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Taper infusion gradually): 1. Tapering the infusion gradually allows for a smooth transition off PN without causing metabolic disturbances. 2. Abruptly stopping PN can lead to hypoglycemia and electrolyte imbalances. 3. Increasing the rate may cause fluid overload or hyperglycemia. 4. Hanging 5% dextrose alone does not provide adequate nutrition and may not meet the patient's needs.
Question 6 of 9
A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond?
Correct Answer: C
Rationale: The correct answer is C because it accurately explains the physiological change in the eye that leads to the need for bifocals. As individuals age, there is a gradual thickening of the lens of the eye, which affects the eye's ability to accommodate for near vision. This thickening makes it harder for the eye to focus on close objects, necessitating the use of bifocals to correct this near vision issue. Choices A, B, and D are incorrect because they do not provide a scientifically accurate explanation for the need for bifocals in older individuals. Option A is dismissive and does not address the specific change in the eye that leads to the need for bifocals. Option B implies aging as a general concept without specifying the relevant change in the eye. Option D incorrectly states that the eye gets shorter as we age, which is not the reason for needing bifocals.
Question 7 of 9
Which behaviors indicate the student nurse hasa good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Selectall that apply.)
Correct Answer: D
Rationale: Correct Answer: D Rationale: - Giving a change-of-shift report to the oncoming nurse about the patient is an appropriate action that maintains confidentiality by only sharing necessary patient information with authorized healthcare professionals. - A: Writing the patient’s room number and date of birth on a paper for school is a breach of confidentiality as it exposes sensitive patient information to unauthorized individuals. - B: Printing/copying material from the patient’s health record for a graded care plan is also a breach of confidentiality as it involves sharing patient information without proper authorization. - C: Reviewing assigned patient’s record and another unassigned patient’s record is a violation of HIPAA as it involves accessing patient information that is not necessary for the nurse's duties, risking unauthorized disclosure.
Question 8 of 9
A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style. A home health nurse is preparing for an initialhome visit. Which information should be included in the patient’s home care medical record?
Correct Answer: D
Rationale: The correct answer is D: Reports to third-party payers. In home health care, it is essential to document and report patient care to third-party payers for reimbursement purposes. This includes detailed reports on the services provided, patient progress, and any changes in the care plan. This information is crucial for ensuring that the patient receives appropriate reimbursement for the care received. Incorrect choices: A: Nursing process form - While a nursing process form is important for documenting patient care, it is not specifically related to reporting to third-party payers. B: Step-by-step skills manual - While a skills manual may be helpful for guiding care provision, it is not typically included in the patient's medical record. C: A list of possible procedures - While a list of procedures may be useful for reference, it is not a formal part of the patient's medical record for home care documentation.
Question 9 of 9
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
Correct Answer: D
Rationale: The correct answer is D: Hold the condom by the cuff upon withdrawal. This is important because holding the condom by the cuff helps prevent any potential spillage of bodily fluids. During withdrawal, holding the condom by the base prevents it from slipping off and minimizes the risk of exposure to sexually transmitted infections. Explanation of why other choices are incorrect: A: Attaching the condom prior to erection is incorrect as it may lead to breakage or slipping off during intercourse. B: Reusing a condom with the same partner is highly discouraged due to the risk of breakage, reduced effectiveness, and potential exposure to infections. C: Using skin lotion as a lubricant is not recommended as it can degrade the condom material, increasing the risk of breakage.