ATI RN
foundations of nursing test bank Questions
Question 1 of 9
The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa?
Correct Answer: C
Rationale: The correct answer is C because African-American ethnicity and previous cesarean birth are established risk factors for placenta previa due to the potential for scarring and abnormal placental implantation. Male fetus does not influence the risk. Asian-American ethnicity and previous preterm birth are not significant risk factors. European-American ethnicity and previous spontaneous abortion are also not associated with an increased risk of placenta previa.
Question 2 of 9
The hospice nurse is caring for a patient with cancer in her home. The nurse has explained to the patient and the family that the patient is at risk for hypercalcemia and has educated them on that signs and symptoms of this health problem. What else should the nurse teach this patient and family to do to reduce the patients risk of hypercalcemia?
Correct Answer: C
Rationale: Rationale: Option C is correct because adequate hydration helps prevent hypercalcemia by promoting the excretion of excess calcium in the urine. This reduces the risk of calcium buildup in the blood. Consuming 2 to 4 liters of fluid daily ensures proper hydration, which is crucial for patients at risk for hypercalcemia. Stool softeners (Option A) are not contraindicated and can help prevent constipation, which may be a side effect of some cancer treatments. Laxatives (Option B) should not be taken daily as they can lead to dehydration and electrolyte imbalances. Restricting calcium intake (Option D) is not the primary intervention for preventing hypercalcemia; rather, maintaining adequate hydration is key.
Question 3 of 9
Which piece of data will the nurse use for “B” when using SBAR?
Correct Answer: C
Rationale: The nurse will use the history of angina for "B" when using SBAR because it provides relevant background information about the patient's cardiac condition. This helps the nurse understand the context of the current situation and make appropriate decisions. Pulse rate of 108 (choice B) is a specific vital sign and not an appropriate choice for "B" in SBAR. Having chest pain (choice A) is important but does not provide the necessary background information like the history of angina does. Oxygen being needed (choice D) is a current intervention and not relevant for "B" in SBAR, which focuses on providing background information.
Question 4 of 9
An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this patient be taught about this diagnosis? Select all that apply
Correct Answer: C
Rationale: The correct answer is C. Cholesteatomas are often the result of chronic otitis media. Chronic otitis media can lead to the formation of cholesteatomas, which are noncancerous but can cause complications if left untreated. Cholesteatomas do not resolve spontaneously (A), are not the result of metastasis (B), do not typically cause intractable neuropathic pain (D), and usually require surgical removal to prevent complications (E). Therefore, educating the patient about the association between chronic otitis media and cholesteatoma is essential for understanding the diagnosis and potential treatment options.
Question 5 of 9
The nurse is planning care for a group of patients.Which task will the nurse assign to the nursing assistive personnel (NAP)?
Correct Answer: C
Rationale: Correct Answer: C - Administering an enema Rationale: Administering an enema is a task that can be safely delegated to nursing assistive personnel (NAP) as it is within their scope of practice and does not require the specialized knowledge and skills of a registered nurse. NAP can be trained to perform enema administration safely and effectively, under the supervision of a nurse. This task involves following a specific procedure and does not require clinical judgment or decision-making. Summary of other choices: A: Performing the first postoperative pouch change - This task involves wound care and assessment, which require the expertise of a registered nurse. B: Maintaining a nasogastric tube - This task involves ongoing assessment, monitoring for complications, and adjustments, which are responsibilities of a registered nurse. D: Digitally removing stool - This task involves invasive procedures and assessment, which are beyond the scope of practice for nursing assistive personnel.
Question 6 of 9
A patient with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate
Correct Answer: D
Rationale: The correct answer is D because the patient's symptoms of pounding headache, visual changes, and epigastric pain are classic signs of worsening preeclampsia, indicating a significant increase in blood pressure and potential progression to eclampsia (seizures). Immediate medical intervention is crucial to prevent complications. A: Gastrointestinal upset does not explain the combination of symptoms presented. B: Magnesium sulfate is used to prevent seizures in preeclampsia but does not cause these specific symptoms. C: Anxiety does not typically present with the specific physical symptoms mentioned.
Question 7 of 9
An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?
Correct Answer: D
Rationale: Correct Answer: D - Avoid rubbing or scratching the affected area Rationale: 1. Rubbing or scratching can further damage the already compromised skin integrity. 2. By avoiding rubbing or scratching, the patient reduces the risk of infection and delayed healing. 3. This intervention promotes skin healing and prevents worsening of the condition. Summary: A: Applying ice pack or heating pad may provide temporary relief but does not address the root cause of impaired skin integrity. B: Avoiding skin contact with water is not necessary and may not directly improve skin integrity. C: Phototherapy is not indicated for erythematous reactions to radiation therapy and may not address the issue.
Question 8 of 9
The nurse in an extended care facility is planning the daily activities of a patient with postpolio syndrome. The nurse recognizes the patient will best benefit from physical therapy when it is scheduled at what time?
Correct Answer: B
Rationale: The correct answer is B: In the morning. This is because scheduling physical therapy in the morning allows the patient to benefit from increased energy levels and improved muscle strength and function after a night of rest. Morning sessions can also help set a positive tone for the rest of the day. Choice A: Immediately after meals can lead to discomfort and potential complications like indigestion or reflux. Choice C: Before bedtime may be too late in the day when fatigue levels are higher and may disrupt sleep patterns. Choice D: In the early evening may be less effective as fatigue accumulates throughout the day, and the patient may not have the same level of energy and focus as in the morning.
Question 9 of 9
A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care?
Correct Answer: A
Rationale: The correct answer is A: Assessing for mouth droop and decreased lateral eye gaze. After a radical mastoidectomy, the nurse should prioritize assessing for signs of facial nerve damage, such as mouth droop and decreased lateral eye gaze, which can indicate injury to the facial nerve during surgery. This is crucial as immediate intervention may be needed to prevent long-term complications. Choices B, C, and D are incorrect: B: Assessing for increased middle ear pressure and perforated ear drum is not the priority postoperative care for a radical mastoidectomy patient. C: Assessing for gradual onset of conductive hearing loss and nystagmus is not the priority as these are not immediate concerns postoperatively. D: Assessing for scar tissue and cerumen obstructing the auditory canal is not the priority as these are not immediate postoperative complications that require urgent attention.