ATI RN
foundation of nursing questions Questions
Question 1 of 9
The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Keep the patient's bed linens free of wrinkles. This intervention is important in preventing pressure ulcers, a common complication in patients with impaired skin integrity. Wrinkles in bed linens can create pressure points on the skin, leading to skin breakdown. By keeping the bed linens smooth and wrinkle-free, the patient's skin is protected from excessive pressure, reducing the risk of impaired skin integrity. A: Maximizing fluid intake is important for overall health but is not directly related to preventing impaired skin integrity. B: Providing total parenteral nutrition may support the patient's nutritional needs but does not specifically address the risk of impaired skin integrity. D: Providing snug clothing can increase friction and pressure on the skin, potentially worsening the risk of impaired skin integrity.
Question 2 of 9
The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is themostlikely cause of the diarrhea?
Correct Answer: C
Rationale: The correct answer is C: Formula intolerance. When a patient develops diarrhea shortly after starting enteral feeding, formula intolerance is the most likely cause. This can occur due to the patient's inability to tolerate certain ingredients in the formula, leading to gastrointestinal upset. Antibiotics (choice A) and Clostridium difficile (choice B) typically take longer to cause diarrhea. Bacterial contamination (choice D) would usually result in more severe symptoms beyond just diarrhea. In this scenario, formula intolerance is the most logical explanation for the immediate onset of diarrhea after starting enteral feeding.
Question 3 of 9
A patient requests the nurse’s help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient’s inability to void?
Correct Answer: A
Rationale: The correct answer is A: The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void. Rationale: Anxiety can lead to tension in the abdominal and perineal muscles, inhibiting the ability to relax and urinate. The sympathetic nervous system response to anxiety can cause urinary retention. So, the patient's frustration in voiding in front of the nurse may be due to anxiety hindering muscle relaxation. Summary of other choices: B: The patient not recognizing physiological signals is less likely as the patient requested assistance to void, indicating awareness of the need to urinate. C: The patient being lonely and seeking attention is not relevant to the inability to void in front of the nurse. D: Inadequate fluid intake may contribute to decreased urine output but is not directly related to the inability to void in front of the nurse.
Question 4 of 9
A patient has been referred to the breast clinic after her most recent mammogram revealed the presence of a lump. The lump is found to be a small, well-defined nodule in the right breast. The oncology nurse should recognize the likelihood of what treatment?
Correct Answer: A
Rationale: The correct answer is A: Lumpectomy and radiation. For a small, well-defined nodule in the breast, lumpectomy (removal of the lump) followed by radiation therapy is usually the treatment of choice for early-stage breast cancer. This approach aims to preserve the breast while ensuring effective treatment. Partial mastectomy (B) involves removing a larger portion of the breast tissue and is not typically necessary for a small, well-defined nodule. Chemotherapy (C) is generally used for more advanced stages of breast cancer or when the cancer has spread beyond the breast. Total mastectomy (D) is considered when the cancer is more extensive or in cases where lumpectomy is not feasible.
Question 5 of 9
The nurse is describing some of the major characteristics of cancer to a patient who has recently received a diagnosis of malignant melanoma. When differentiating between benign and malignant cancer cells, the nurse should explain differences in which of the following aspects? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Rate of growth. Malignant cancer cells grow and divide rapidly compared to benign cells. Benign cells are usually slow-growing and have a well-defined border, while malignant cells grow uncontrollably and invade surrounding tissues. The other choices are incorrect because: B: Ability to cause death - Both benign and malignant cells have the potential to cause harm, but the key difference lies in their growth rate and invasiveness. C: Size of cells - The size of cells does not necessarily differentiate between benign and malignant cells. D: Cell contents - While malignant cells may have abnormal cell contents, this is not a defining characteristic when differentiating between benign and malignant cells. E: Ability to spread - While the ability to spread is a key characteristic of malignant cells, the primary differentiating factor in this question is the rate of growth.
Question 6 of 9
The nurse in a pediatric ICU is caring for a child who is dying of sickle cell anemia. The childs mother has been unable to eat or sleep and can talk only about her impending loss and the guilt she feels about the childs pain and suffering. What intervention has the highest priority?
Correct Answer: A
Rationale: The correct answer is A: Allowing the patient to express her feelings without judging her. This intervention has the highest priority as it focuses on providing emotional support and creating a safe space for the mother to express her emotions without feeling judged. In this situation, the mother is experiencing intense guilt and grief, and allowing her to talk about her feelings can help her process her emotions and cope with the impending loss. By listening actively and without judgment, the nurse can demonstrate empathy and compassion, which are crucial in supporting the mother through this difficult time. Summary: B: Helping the patient to understand the phases of the grieving process may be helpful, but it is not the highest priority at this moment. C: Reassuring the patient that the child's death is not her fault is important, but the priority is to address the mother's emotional needs first. D: Arranging for genetic counseling is not the highest priority at this time as the immediate focus should be on providing emotional support to the mother
Question 7 of 9
A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patients health status?
Correct Answer: A
Rationale: Step 1: Serous otitis media is common in children due to eustachian tube dysfunction, not usually related to systemic infections. Step 2: Recurrent infections may indicate age-related changes like decreased eustachian tube function. Step 3: Age-related physiologic changes can lead to poor drainage, causing recurrent otitis media. Step 4: Therefore, choice A is correct as it aligns with the typical presentation of serous otitis media in the context of age. Summary: Choice B is incorrect as there is no indication for temporary mobility restriction. Choice C is incorrect as serous otitis media does not typically warrant assessment for nasopharyngeal cancer. Choice D is incorrect as blood cultures are not typically indicated for serous otitis media.
Question 8 of 9
A nurse is completing an OASIS data set on apatient. The nurse works in which area?
Correct Answer: A
Rationale: The correct answer is A: Home health. The Outcome and Assessment Information Set (OASIS) data set is specifically used in the home health care setting to assess the patient's condition and needs. This includes collecting data on the patient's health, functional status, and living environment to determine the appropriate care plan. In contrast, choices B, C, and D are incorrect because OASIS is not utilized in the intensive care unit, skilled nursing facility, or long-term care facility settings. These settings have their own assessment tools and documentation requirements that are different from OASIS used in home health care.
Question 9 of 9
A nurse is using core measures to reduce healthdisparities. Which group should the nurse focus on to cause themost improvement in core measures?
Correct Answer: B
Rationale: The correct answer is B: Poor people. Focusing on poor people is likely to cause the most improvement in core measures because individuals living in poverty often face multiple barriers to accessing healthcare and have higher rates of chronic conditions. By targeting this group, the nurse can address social determinants of health, improve healthcare access, and address disparities in healthcare outcomes. Other choices (A, C, D) are not as impactful as poverty is a significant factor influencing health disparities.