ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?
Correct Answer: D
Rationale: The correct answer is D: Pneumocystis pneumonia. This is the most common life-threatening infection in HIV-positive patients with low CD4+ counts. Pneumocystis pneumonia is caused by the opportunistic pathogen Pneumocystis jirovecii, which can lead to severe respiratory distress and mortality in immunocompromised individuals. The other choices, A: Salmonella infection, B: Mycobacterium tuberculosis, and C: Clostridium difficile, can also cause infections in HIV-positive patients, but they are not as commonly associated with life-threatening complications in this population compared to Pneumocystis pneumonia. It is crucial for the nurse to prioritize assessment for signs and symptoms of Pneumocystis pneumonia in this patient to promptly intervene and prevent further complications.
Question 2 of 9
A patient with Parkinsons disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patients nutritional needs should be met by what method?
Correct Answer: C
Rationale: The correct answer is C: Semisolid food with thick liquids. Patients with Parkinson's disease often have dysphagia, leading to aspiration and respiratory complications. Semisolid food with thick liquids helps prevent aspiration and promotes safer swallowing. TPN (A) is not necessary for meeting nutritional needs unless the patient cannot tolerate oral intake. A low-residue diet (B) may not address the specific swallowing issues in Parkinson's disease. Minced foods and fluid restriction (D) may not provide adequate nutrition and hydration.
Question 3 of 9
You are caring for a patient, a 42-year-old mother of two children, with a diagnosis of ovarian cancer. She has just been told that her ovarian cancer is terminal. When you admitted this patient, you did a spiritual assessment. What question would it have been most important for you to evaluate during this assessment?
Correct Answer: B
Rationale: The correct answer is B: Does she have a sense of peace of mind and a purpose to her life? This question is crucial during a spiritual assessment because it addresses the patient's emotional well-being and coping mechanisms in the face of a terminal diagnosis. It helps assess the patient's spiritual beliefs, values, and sources of strength, which can impact their ability to find meaning and comfort during difficult times. It also provides insights into the patient's resilience and ability to navigate their emotions and find peace amidst uncertainty. Choice A is incorrect because it focuses on the patient's ability to deliver negative news to her family, which is important but not as central to the patient's spiritual well-being in this context. Choice C is incorrect as it assumes the patient needs to let go of her husband, which may not be relevant to her spiritual assessment. Choice D is incorrect as it centers on bargaining with God for a cure, which may not be reflective of the patient's spiritual beliefs or needs.
Question 4 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 5 of 9
The nurse is caring for a patient who is to begin receiving external radiation for a malignant tumor of the neck. While providing patient education, what potential adverse effects should the nurse discuss with the patient?
Correct Answer: A
Rationale: The correct answer is A: Impaired nutritional status. Radiation therapy to the neck can lead to mucositis, dysphagia, and taste changes, which can impair the patient's ability to eat and maintain adequate nutrition. This can lead to weight loss, weakness, and delayed wound healing. Discussing this potential adverse effect with the patient is crucial for proactive management. Choice B: Cognitive changes, and Choice C: Diarrhea are less likely to be direct adverse effects of radiation therapy to the neck. Cognitive changes are more commonly associated with brain radiation, while diarrhea is a more common side effect of abdominal radiation. Choice D: Alopecia is a side effect of chemotherapy, not radiation therapy. Radiation therapy does not typically cause hair loss unless it is in the treatment field. Therefore, discussing alopecia with the patient receiving radiation for a malignant neck tumor is not a priority.
Question 6 of 9
An adolescent is identified as having a collection of fluid in the tunica vaginalis of his testes. The nurse knows that this adolescent will receive what medical diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Hydrocele. A hydrocele is the collection of fluid in the tunica vaginalis of the testes. This condition is common in newborns and can also occur in adolescents. Cryptorchidism (A) is the absence of one or both testes from the scrotum. Orchitis (B) is inflammation of the testicles. Prostatism (D) is a non-specific term related to prostate issues, not relevant to the given scenario. Therefore, the correct diagnosis for an adolescent with fluid collection in the tunica vaginalis of his testes is hydrocele.
Question 7 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.
Question 8 of 9
A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?
Correct Answer: C
Rationale: The correct choice is C because if no urine is obtained, it indicates that the catheter is not in the urethra. The nurse should remove the catheter, wipe with alcohol to maintain cleanliness, and reinsert after lubrication to ensure proper placement in the urethra. This step-by-step approach allows for a more accurate catheter insertion and prevents potential complications. Choice A is incorrect as discarding the catheter and starting over without addressing the issue does not solve the problem. Choice B is incorrect as filling the balloon with sterile water is not relevant to the situation of catheter misplacement. Choice D is incorrect as leaving the catheter in the vagina can lead to infection and is not a recommended practice.
Question 9 of 9
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patients plan of care. The presence of what chronic health problem would most likely prompt this diagnosis?
Correct Answer: D
Rationale: The correct answer is D: Hypogammaglobulinemia. This chronic health problem predisposes individuals to latex allergies due to reduced levels of immunoglobulins, increasing susceptibility to allergic reactions. Latex contains proteins that can trigger immune responses in individuals with compromised immune systems. Choice A: Herpes simplex is a viral infection and does not directly relate to latex allergies. Choice B: HIV weakens the immune system but is not specifically associated with latex allergies. Choice C: Spina bifida is a congenital condition affecting the spinal cord and does not directly impact the likelihood of latex allergies.