ATI RN
foundation of nursing practice questions Questions
Question 1 of 9
An older adult patient has been diagnosed with macular degeneration and the nurse is assessing him for changes in visual acuity since his last clinic visit. When assessing the patient for recent changes in visual acuity, the patient states that he sees the lines on an Amsler grid as being distorted. What is the nurses most appropriate response?
Correct Answer: C
Rationale: Distorted lines on an Amsler grid can be an indication of changes in central vision, which is commonly seen in macular degeneration. Therefore, it is crucial for the nurse to arrange for the patient to visit his ophthalmologist promptly for further evaluation and management. The ophthalmologist will be able to determine the severity of the visual changes, provide appropriate treatment options, and closely monitor the progression of macular degeneration. This proactive approach ensures that the patient receives timely and specialized care for his condition. Options A, B, and D do not directly address the urgency of the situation and the need for specialized ophthalmologic evaluation in cases of macular degeneration.
Question 2 of 9
A patient confides to the nurse that he cannot engage in sexual activity. The patient is 27 years old and has no apparent history of chronic illness that would contribute to erectile dysfunction. What does the nurse know will be ordered for this patient to assess his sexual functioning?
Correct Answer: D
Rationale: Nocturnal penile tumescence tests are used to assess erectile dysfunction in men who are unable to engage in sexual activity. It measures the frequency and strength of erections that occur during sleep, which can provide valuable information about a man's erectile function and whether there may be underlying physiological causes for his inability to engage in sexual activity. This test can help determine if the patient's erectile dysfunction is due to physical or psychological factors. A sperm count, ejaculation capacity tests, and engorgement tests are not typically ordered to assess sexual functioning in this case.
Question 3 of 9
While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurses most appropriate action?
Correct Answer: B
Rationale: The most appropriate action for the nurse to take when observing the surgical dressing saturated with serosanguineous drainage is to reinforce the dressing and reassess in 1 to 2 hours. Serosanguineous discharge is a common type of drainage following surgery, as it is a mixture of blood and serum. It is expected in the early stages of wound healing and does not necessarily indicate infection. By reinforcing the dressing and closely monitoring the drainage over the next couple of hours, the nurse can assess if the amount of drainage is decreasing or escalating. If there are any signs of infection, such as increasing redness, warmth, swelling, or excessive purulent discharge, then the nurse should notify the physician promptly. Until then, it is appropriate to continue observing and managing the drainage within the expected range.
Question 4 of 9
Draw up prescribed amount of sterile solution ordered.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 9
A nurse is assessing population groups for therisk of suicide requiring medical attention. Which group should the nurse monitormostclosely?
Correct Answer: A
Rationale: Gay, lesbian, and bisexual young people have a significantly increased risk for depression, anxiety, suicide attempts, and substance use disorders. In particular, bisexual youth are at a higher risk than their straight peers for experiencing mental health issues and suicide attempts that require medical attention. Studies have shown that young bisexuals are four times more likely than their straight counterparts to make suicide attempts that necessitate medical intervention. Therefore, it is crucial for the nurse to closely monitor this population group for signs of suicidal behavior and provide the necessary support and interventions to prevent such tragedies.
Question 6 of 9
The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
Correct Answer: B
Rationale: The signs of magnesium toxicity that the nurse should monitor for in a patient with severe preeclampsia on IV magnesium sulfate include an altered sensorium (confusion, lethargy, slurred speech) and a respiratory rate of less than 12 breaths per minute. Altered sensorium is a common symptom of magnesium toxicity, reflecting the drug's central nervous system depressant effects. A decreased respiratory rate can indicate respiratory depression, a potentially serious complication of magnesium toxicity. Monitoring for these signs is crucial to promptly identifying and managing magnesium toxicity in patients on magnesium sulfate therapy. Signs such as cool, clammy skin and a pulse oximeter reading of 95% would not be indicative of magnesium toxicity.
Question 7 of 9
The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement?
Correct Answer: B
Rationale: After a mastoidectomy, the ear should be protected from water for several weeks. This is because exposing the area to water can increase the risk of infection. Keeping the ear dry allows the surgical site to heal properly and reduces the likelihood of postoperative complications such as infection. Therefore, instructing the patient to protect the ear from water is an important intervention to prevent postoperative infection following a mastoidectomy.
Question 8 of 9
A patient comes to the clinic complaining of a tender, inflamed vulva. Testing does not reveal the presence of any known causative microorganism. What aspect of this patients current health status may account for the patients symptoms of vulvitis?
Correct Answer: A
Rationale: Morbid obesity is a risk factor for developing a condition known as intertrigo, which is inflammation of the skin folds. In this case, the skin folds of the vulva are affected, leading to vulvitis. The warm and moist environment between the skin folds in obese individuals can promote the growth of microorganisms and the development of inflammation. This can result in symptoms such as tenderness and redness in the vulva. Since testing did not reveal the presence of any known causative microorganism, the patient's morbid obesity may be the underlying factor contributing to the symptoms of vulvitis. Treating the intertrigo and addressing the underlying obesity may help alleviate the symptoms.
Question 9 of 9
The priority nursing intervention when admitting a pregnant patient who has experienced a bleeding episode in late pregnancy is to
Correct Answer: B
Rationale: When admitting a pregnant patient who has experienced a bleeding episode in late pregnancy, the top priority nursing intervention is to assess fetal heart rate (FHR) and maternal vital signs. This assessment will help the nurse determine the extent of the blood loss and its impact on both the mother and the fetus. Monitoring uterine contractions is important as well, but not the priority in this situation. Placing clean disposable pads to collect any drainage is important for ongoing assessment and management but can be done after assessing the FHR and vital signs. Performing a venipuncture for hemoglobin and hematocrit levels is necessary for further evaluation but can be done after the initial assessment of FHR and vital signs. Checking the patient and fetal well-being is crucial in situations of bleeding in late pregnancy to ensure timely and appropriate intervention.