ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
Fraternal twins are delivered by your Rh-negative patient. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the
Correct Answer: C
Rationale: The correct answer is C: indirect Coombs test of the mother. This test is crucial to determine if the mother has developed antibodies against the Rh-positive blood of twin A, which could lead to hemolytic disease of the newborn in future pregnancies. A direct Coombs test of twin A or twin B is not relevant in this scenario as it does not provide information about the mother's antibody status. Transcutaneous bilirubin levels are used to monitor jaundice in newborns and not related to Rh incompatibility. In summary, the indirect Coombs test of the mother is the most relevant test to assess the risk of hemolytic disease in future pregnancies.
Question 2 of 9
The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what potential complications?
Correct Answer: B
Rationale: The correct answer is B: Hematoma at the surgical site. This is a potential complication of cervical discectomy due to the risk of bleeding post-surgery. Hematoma can compress nearby structures and lead to increased pain and swelling. A: Vertebral fracture is not a typical complication of cervical discectomy, as the surgery aims to relieve pressure on the spinal cord caused by a herniated disc, not to cause fractures. C: Scoliosis is a condition characterized by abnormal lateral curvature of the spine, and it is not directly related to cervical discectomy. D: Renal trauma is not a common complication of cervical discectomy, as the surgery focuses on the cervical spine and does not involve the kidneys or renal system.
Question 3 of 9
You are caring for a patient who has been diagnosed with genital herpes. When preparing a teaching plan for this patient, what general guidelines should be taught?
Correct Answer: A
Rationale: The correct answer is A because thorough handwashing is essential in preventing the spread of genital herpes. This helps reduce the risk of transmission to other parts of the body or to other individuals. Sunbathing (B) does not eradicate the virus and can actually worsen symptoms. Massaging lesions with ointment (C) can aggravate the sores and lead to further infection. Self-infection (D) can occur from touching lesions during a breakout due to the highly contagious nature of the virus. Therefore, teaching the patient about thorough handwashing is crucial in managing and preventing the spread of genital herpes.
Question 4 of 9
The hospice nurse is caring for a 45-year-old mother of three young children in the patients home. During the most recent visit, the nurse has observed that the patient has a new onset of altered mental status, likely resulting from recently diagnosed brain metastases. What goal of nursing interventions should the nurse identify?
Correct Answer: D
Rationale: The correct answer is D. The goal of nursing interventions in this scenario is to teach family members how to interact with and ensure safety for the patient with impaired cognition. This is the most appropriate response because it addresses the immediate need to provide the patient with appropriate care and support in their home environment. By educating the family on how to interact with the patient and ensure their safety, the nurse can help maintain a sense of normalcy for the patient and promote their well-being. Choice A is incorrect because sedating the patient may not be the best approach without considering other interventions first. Choice B is incorrect as moving the patient to an acute-care facility may not be necessary or feasible at this time. Choice C is incorrect as it focuses on end-of-life care rather than addressing the immediate need of supporting the patient with altered mental status.
Question 5 of 9
A nurse is teaching the staff about health carereimbursement. Which information should the nurse include in the teaching session?
Correct Answer: A
Rationale: The correct answer is A because documentation by nurses in various settings like home health, long-term care, and hospitals impacts reimbursement. Proper documentation ensures services provided are accurately reflected, influencing reimbursement. Choice B is incorrect as it refers to Meaningful Use requirements for EHRs, not reimbursement. Choice C is incorrect as a "near miss" relates to patient safety, not reimbursement. Choice D is incorrect because HIPAA focuses on privacy and security of patient information, not reimbursement.
Question 6 of 9
A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for infection related to myelosuppression. What intervention addresses the leading cause of infection- related death in oncology patients?
Correct Answer: D
Rationale: The correct answer is D: Assess the integrity of the patients oral mucosa regularly. Myelosuppression leads to decreased white blood cells, increasing infection risk. The oral mucosa can be a common site for infections. Regular assessment helps in early detection and intervention. A: Encouraging small meals does not directly address infection risk in myelosuppressed patients. B: Providing skin care is important for overall patient care but does not directly address the leading cause of infection-related death. C: Assisting with hygiene is important but does not specifically target the leading cause of infection-related death in oncology patients.
Question 7 of 9
A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action?
Correct Answer: A
Rationale: The correct answer is A because instilling the medication in the conjunctival sac allows for direct absorption into the eye tissues. This method ensures that the medication reaches the target area for treating glaucoma effectively. Maintaining a supine position (choice B) or keeping the eyes closed (choice C) after administration does not enhance absorption and may lead to wasted medication. Applying the medication to the sclera (choice D) is incorrect as it does not target the specific area needed for treating glaucoma.
Question 8 of 9
A patient diagnosed with Bells palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles?
Correct Answer: A
Rationale: The correct answer is A: Blowing up balloons. Blowing up balloons involves the activation of the facial muscles, which helps prevent muscle atrophy in patients with Bell's palsy. This exercise promotes muscle strength and prevents weakness. Deliberately frowning (B), smiling repeatedly (C), and whistling (D) do not specifically target the facial muscles involved in Bell's palsy and may not be as effective in preventing muscle atrophy.
Question 9 of 9
A patient has had a total mastectomy with immediate reconstruction. The patient asks the nurse when she can take a shower. What should the nurse respond?
Correct Answer: A
Rationale: The correct answer is A: Not until the drain is removed. After a mastectomy with immediate reconstruction, there is typically a drain in place to collect fluid. Showering before the drain is removed can increase the risk of infection and disrupt the healing process. It is important to wait until the healthcare provider removes the drain to ensure proper healing and reduce the risk of complications. Summary: B: On the second postoperative day - Too early, the drain needs to be removed first. C: Now, if you wash gently with soap and water - Incorrect, the drain should be removed before showering. D: Seven days after your surgery - Incorrect, waiting for a specific number of days is not necessary, it depends on when the drain is removed.