ATI RN
test bank foundations of nursing Questions
Question 1 of 9
Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely cause this abnormality?
Correct Answer: A
Rationale: The correct answer is A: Rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, which includes bilateral cataracts as a characteristic feature. Rubella virus can cross the placenta and affect the developing fetus. Cytomegalovirus (CMV) can also cause congenital cataracts, but rubella is more commonly associated with this abnormality. Syphilis can cause other congenital abnormalities but not bilateral cataracts. HIV does not typically lead to bilateral cataracts in newborns.
Question 2 of 9
A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond?
Correct Answer: C
Rationale: The correct answer is C because it acknowledges that many HIV patients use alternative therapies and emphasizes the importance of weighing the benefits and risks. This response shows respect for the patient's autonomy and preferences while also recognizing the need for informed decision-making. Choice A is incorrect because it dismisses complementary therapies outright without considering individual patient needs or preferences. Choice B is incorrect as it suggests avoiding alternative therapies entirely, which may not align with the patient's wishes or experiences. Choice D is incorrect as it presents a false dichotomy between alternative and medical approaches, disregarding the possibility of integrating both types of treatments.
Question 3 of 9
Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication?
Correct Answer: C
Rationale: The correct answer is C: Normal deep tendon reflexes. This indicates a therapeutic level of magnesium sulfate as it shows that the medication is effectively preventing hyperreflexia, a common sign of magnesium toxicity. Drowsiness (choice A) can indicate toxicity. Urinary output of 20 mL/hour (choice B) is not specific to magnesium sulfate levels. Respiratory rate of 10 to 12 breaths per minute (choice D) is indicative of respiratory depression, a sign of magnesium toxicity. Thus, choice C is the best assessment to indicate a therapeutic level of medication in a patient with preeclampsia taking magnesium sulfate.
Question 4 of 9
The nurse is caring for a patient who has just had a radical mastectomy and axillary node dissection. When providing patient education regarding rehabilitation, what should the nurse recommend?
Correct Answer: C
Rationale: The correct answer is C: Avoid lifting objects heavier than 10 pounds. This recommendation is crucial post-mastectomy as it helps prevent lymphedema and promotes healing without causing strain on the surgical site. Lifting heavy objects can lead to complications such as lymphedema or disruption of the healing process. Options A, B, and D are incorrect as avoiding exercise of the arm for 2 months may lead to stiffness and reduced range of motion, keeping cuticles clipped neatly does not directly affect rehabilitation, and using a sling is not necessary unless specifically advised by the healthcare provider.
Question 5 of 9
A patient with Parkinsons disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond?
Correct Answer: C
Rationale: The correct answer is C: Lets explore other options, because laxatives can have side effects and create dependency. The rationale for this is that while laxatives provide temporary relief for constipation, using them long-term can lead to dependency, electrolyte imbalances, and other side effects. The nurse should address the root cause of constipation and explore alternative strategies such as dietary changes, increased fluid intake, exercise, and bowel training. Choices A and B focus on supportive measures rather than addressing the issue of potential dependency on laxatives. Choice D suggests herbal remedies without considering the individual's specific condition and medical history.
Question 6 of 9
Which of the following nurses actions carries the greatest potential to prevent hearing loss due to ototoxicity?
Correct Answer: D
Rationale: The correct answer is D because being aware of patients' medication regimens allows nurses to identify and monitor ototoxic medications that can cause hearing loss. By collaborating with other professionals, nurses can adjust medications or recommend alternative treatments to prevent or minimize ototoxicity. This proactive approach directly targets the root cause of potential hearing loss. A: Understanding types of hearing loss is important but does not directly prevent ototoxicity. B: Educating about age-related changes in hearing does not address ototoxicity prevention. C: Educating about noise exposure risks is important for overall hearing health but does not specifically prevent ototoxicity.
Question 7 of 9
A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Current medication regimen. In the admission assessment of a patient with AIDS, it is crucial to assess the patient's current medication regimen to ensure proper management of the condition. This includes antiretroviral therapy, prophylactic medications, and any other medications the patient may be taking to manage comorbidities. Understanding the medications the patient is currently taking allows the nurse to assess for potential drug interactions, side effects, and adherence to the treatment plan. This information is essential for providing safe and effective care for the patient. Choice B: Identification of patients support system is important but not a specific component of the comprehensive assessment for a patient with AIDS. Choice C: Immune system function is a relevant aspect in a patient with AIDS, but it is not typically assessed in the admission assessment as it requires specialized testing. Choice D: Genetic risk factors for HIV are not typically assessed in the admission assessment of a patient with AIDS as the focus is on the current condition and management
Question 8 of 9
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?
Correct Answer: C
Rationale: The correct answer is C because putting on a second pair of gloves over soiled gloves during a procedure violates standard precautions by increasing contamination risk. Here's the rationale: 1. Standard precautions require removing soiled gloves before putting on new ones to prevent cross-contamination. 2. Wearing multiple gloves increases the risk of tearing and exposure to pathogens. 3. This behavior shows a lack of understanding of proper infection control practices. Summary of other choices: A: Wearing face protection, gloves, and a gown when irrigating a wound is a correct practice. B: Washing hands with waterless antiseptic after removing soiled gloves is correct. D: Placing a used needle and syringe in a puncture-resistant container without capping the needle is incorrect, but not as severe as choice C.
Question 9 of 9
A nurse exchanges information with the oncomingnurse about a patient’s care. Which action did the nurse complete?
Correct Answer: A
Rationale: The correct answer is A: A verbal report. This is because exchanging information verbally between nurses allows for real-time communication, ensuring important details are accurately conveyed. Electronic record entry (B) involves documenting information in the patient's record but does not involve direct communication. Referral (C) refers to transferring the patient's care to another healthcare provider. Acuity rating (D) is a tool used to determine the severity of a patient's condition and does not involve exchanging information between nurses.