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
A patient has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray?
Correct Answer: A
Rationale: The correct answer is A because using clock cues helps the patient visualize the placement of items based on a familiar concept. This aids in compensating for the loss of vision after head trauma. Choice B does not provide specific guidance on how to describe the placement. Choice C may be confusing for the patient as it is not a common way to describe item placement. Choice D puts unnecessary burden on the patient to describe the location first before confirming, which may be challenging for someone with sudden loss of vision.
Question 3 of 9
Which behaviors indicate the nurse is using criticalthinking standards when communicating with patients? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: Uses humility. Critical thinking in nursing involves being open-minded, self-aware, and willing to consider different perspectives. Humility allows nurses to acknowledge their limitations, seek feedback, and continuously learn and improve. Instilling faith (A) may be important but does not directly relate to critical thinking standards. Self-confidence (C) can be beneficial, but excessive confidence can lead to closed-mindedness. Supportiveness (D) is valuable in patient care but does not specifically demonstrate critical thinking standards. In summary, humility enables nurses to approach patient communication with an open and reflective mindset, essential for applying critical thinking standards effectively.
Question 4 of 9
Which intrapartal assessment should be avoided when caring for a patient with HELLP syndrome?
Correct Answer: A
Rationale: The correct answer is A: Abdominal palpation. Palpating the abdomen can potentially cause rupture of the liver in patients with HELLP syndrome due to increased risk of liver hematoma. This can lead to severe bleeding and compromise the patient's condition. Checking deep tendon reflexes (C), auscultation of the heart and lungs (D), and venous sample of blood (B) are safe assessments that do not pose a risk of exacerbating the patient's condition. It is crucial to prioritize patient safety and avoid interventions that can harm the patient, making avoiding abdominal palpation the correct choice in caring for a patient with HELLP syndrome.
Question 5 of 9
A nurse is preparing to document a patient whohas chest pain. Which information is critical for the nurse to include?
Correct Answer: D
Rationale: The correct answer is D because documenting the patient's pain intensity using a pain scale (8 out of 10) is crucial for assessing the severity of the chest pain. This information helps in determining the appropriate intervention and monitoring the effectiveness of treatment. Choice A is irrelevant as it does not provide any useful information about the patient's condition. Choice B is important for neurological assessment but not specifically related to chest pain. Choice C is not as critical as knowing the current pain level.
Question 6 of 9
A patient develops a foodborne disease fromEscherichiacoli. When taking a health history, which food item will the nursemostlikely find the patient ingested?
Correct Answer: B
Rationale: The correct answer is B: Undercooked ground beef. Escherichia coli is commonly found in undercooked ground beef, especially if it is contaminated during processing. Ground beef must be cooked to a safe internal temperature to kill any harmful bacteria. Improperly home-canned food (choice A) can also cause foodborne illnesses, but E. coli is more commonly associated with undercooked ground beef. Soft cheese (choice C) is often linked to Listeria contamination, not E. coli. Custard (choice D) is a less likely source of E. coli compared to undercooked ground beef.
Question 7 of 9
A patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurses best response?
Correct Answer: A
Rationale: The correct answer is A because it shows empathy and offers the patient an opportunity to express their feelings. By acknowledging the patient's frustration and anger, the nurse validates their emotions and creates a safe space for communication. This response promotes trust and understanding, which are crucial in building a therapeutic relationship. Choice B is incorrect because it immediately jumps to teaching coping strategies without addressing the patient's emotional state. Choice C is incorrect as it generalizes the patient's feelings without directly engaging with their specific concerns. Choice D is incorrect as it sounds dismissive and may make the patient feel judged or misunderstood. These responses lack the empathetic approach needed to effectively support the patient in this situation.
Question 8 of 9
A nurse has provided care to a patient. Whichentry should the nurse document in the patient’s record?
Correct Answer: C
Rationale: The correct answer is C because it provides specific, objective information about the patient's left knee incision, including its size and absence of concerning signs. This entry is relevant, concise, and focuses on a specific aspect of the patient's condition, aiding in continuity of care and treatment planning. Choice A is vague and lacks detail, making it insufficient for accurate patient care documentation. Choice B focuses on the patient's subjective feelings and does not provide objective assessment data. Choice D is judgmental and includes unnecessary information about the patient's behavior and family presence, which is not directly related to the patient's condition.
Question 9 of 9
A nurse is using therapeutic communication witha patient. Which technique will the nurse use to ensure effective communication?
Correct Answer: A
Rationale: The correct answer is A because therapeutic communication focuses on building a trusting relationship and understanding the patient's feelings and needs. By changing negative self-talk to positive self-talk, the nurse can help the patient develop a more positive outlook and improve self-esteem. This technique promotes effective communication by creating a supportive and non-judgmental environment. Option B is incorrect because small group communication is not the primary focus of therapeutic communication. Option C is incorrect as electronic communication lacks the personal interaction needed for therapeutic communication. Option D is incorrect because intrapersonal communication involves self-reflection and is not directly related to building strong teams in the context of patient care.