ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding?
Correct Answer: A
Rationale: The correct answer is A: The patient's hearing is likely normal. This interpretation is based on the normal Rinne test result, where air-conducted sound is expected to be louder than bone-conducted sound. This finding indicates that the patient has intact air conduction and no significant conductive hearing loss. Option B is incorrect because tinnitus is not directly related to the Rinne test results. Option C is incorrect as otosclerosis would typically present with abnormal Rinne test results showing bone-conducted sound to be louder. Option D is incorrect as sensorineural hearing loss would not typically affect the Rinne test results in this way.
Question 2 of 9
The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patients tumor, the nurse should implement measures to prevent what complication?
Correct Answer: A
Rationale: The correct answer is A: Falls. A cerebellar tumor can affect coordination and balance, leading to an increased risk of falls. Measures to prevent falls include maintaining a clutter-free environment, using assistive devices, and providing supervision. Choice B (Audio hallucinations) is incorrect as cerebellar tumors typically do not cause auditory hallucinations. Choice C (Respiratory depression) is incorrect as cerebellar tumors do not directly affect the respiratory system. Choice D (Labile BP) is incorrect as cerebellar tumors are not typically associated with blood pressure fluctuations.
Question 3 of 9
The nurse is caring for patients with ostomies.In which ostomy location will the nurse expect very liquid stool to be present?
Correct Answer: C
Rationale: The correct answer is C: Ascending. Stool consistency varies based on the location of the ostomy. The ascending colon is responsible for absorbing water from stool, so an ostomy in this location will have very liquid stool. Sigmoid, transverse, and descending colons are responsible for further solidifying stool, so ostomies in those locations would not typically have very liquid stool.
Question 4 of 9
A 27-year-old female patient is diagnosed with invasive cervical cancer and is told she needs to have a hysterectomy. One of the nursing diagnoses for this patient is disturbed body image related to perception of femininity. What intervention would be most appropriate for this patient?
Correct Answer: B
Rationale: The correct answer is B: Reassure the patient that she does not have to have sex to be feminine. Rationale: 1. Acknowledges patient's feelings: By reassuring the patient that she does not have to have sex to be feminine, the nurse validates the patient's emotions and concerns. 2. Addresses societal norms: This intervention challenges societal stereotypes that equate femininity solely with reproductive capabilities. 3. Promotes self-acceptance: Encouraging the patient to embrace her femininity beyond physical aspects fosters self-acceptance and self-worth. 4. Supports holistic care: Recognizing the multifaceted nature of femininity shows a holistic approach to addressing the patient's body image issues. Summary: A, C, and D are incorrect as they do not directly address the patient's specific concerns about her body image and femininity. Choice B is the most appropriate intervention as it validates the patient's feelings and challenges societal norms, promoting self-acceptance and holistic care
Question 5 of 9
Before giving the patient an intermittent gastric tube feeding, what should the nurse do?
Correct Answer: B
Rationale: The correct answer is B because injecting air into the stomach via the tube and auscultating helps confirm the tube placement in the stomach before administering the feeding. This step ensures the safety of the patient by preventing accidental lung feeding. Choice A is incorrect because securing the tube with a safety pin to the gown is not a standard practice and can lead to complications. Choice C is incorrect because the temperature of the feeding does not affect the tube placement or safety. Choice D is incorrect because checking the pH level is not a reliable method for verifying tube placement.
Question 6 of 9
A 66-year-old patient is in a hospice receiving palliative care for lung cancer which has metastasized to the patients liver and bones. For the past several hours, the patient has been experiencing dyspnea. What nursing action is most appropriate to help to relive the dyspnea the patient is experiencing?
Correct Answer: B
Rationale: The correct answer is B: Initiate high-flow oxygen therapy. Dyspnea in a patient with lung cancer can be caused by hypoxia due to compromised lung function. High-flow oxygen therapy can help improve oxygenation and alleviate dyspnea. Administering a bolus of normal saline (A) would not directly address the underlying cause of dyspnea. Administering high doses of opioids (C) may lead to respiratory depression and should be used cautiously in patients experiencing dyspnea. Administering bronchodilators and corticosteroids (D) may be appropriate for certain types of dyspnea, but in this case, addressing hypoxia with high-flow oxygen therapy is the most appropriate initial nursing action.
Question 7 of 9
An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding?
Correct Answer: A
Rationale: The correct answer is A: The patient's hearing is likely normal. This interpretation is based on the normal Rinne test result, where air-conducted sound is expected to be louder than bone-conducted sound. This finding indicates that the patient has intact air conduction and no significant conductive hearing loss. Option B is incorrect because tinnitus is not directly related to the Rinne test results. Option C is incorrect as otosclerosis would typically present with abnormal Rinne test results showing bone-conducted sound to be louder. Option D is incorrect as sensorineural hearing loss would not typically affect the Rinne test results in this way.
Question 8 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 9 of 9
A nurse practitioner assesses the patient and diagnoses Gardnerella vaginalis. What would be the most appropriate nursing action at this time?
Correct Answer: A
Rationale: The correct answer is A: Advise the patient that this is an overgrowth of normal vaginal flora. This is correct because Gardnerella vaginalis is a bacteria associated with bacterial vaginosis, which is an overgrowth of normal vaginal flora. By advising the patient of this, the nurse practitioner can provide education on the condition and treatment options. B: Discussing the effect of this diagnosis on the patient's fertility is incorrect as Gardnerella vaginalis is not typically associated with fertility issues. C: Documenting the vaginal discharge as normal is incorrect as Gardnerella vaginalis is indicative of an abnormal vaginal flora imbalance. D: Administering acyclovir as ordered is incorrect as acyclovir is an antiviral medication used to treat herpes simplex virus infections, not bacterial vaginosis caused by Gardnerella vaginalis.