ATI RN
foundation of nursing questions Questions
Question 1 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 2 of 9
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patients care, what nursing diagnosis should be prioritized?
Correct Answer: D
Rationale: The correct answer is D: Risk for Impaired Gas Exchange Related to Airway Obstruction. This should be prioritized because hereditary angioedema can lead to swelling in the airway, potentially causing respiratory distress and compromising gas exchange. This nursing diagnosis addresses the immediate threat to the patient's respiratory function. A: Risk for Infection Related to Skin Sloughing - While skin sloughing can occur with hereditary angioedema, it is not the priority over ensuring adequate gas exchange. B: Risk for Acute Pain Related to Loss of Skin Integrity - Pain management is important, but addressing airway obstruction takes precedence due to the potential for respiratory compromise. C: Risk for Impaired Skin Integrity Related to Cutaneous Lesions - Skin integrity issues may be present but do not pose as immediate a threat as airway obstruction.
Question 3 of 9
The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk?
Correct Answer: A
Rationale: The correct answer is A: Providing thorough oral care before and after meals. This addresses the risk for impaired skin integrity related to Candidiasis in patients with stage 3 HIV by preventing oral Candidiasis, a common fungal infection. Poor oral hygiene can lead to Candidiasis, which can spread to the skin. Thorough oral care reduces the risk of oral Candidiasis, thereby preventing skin integrity issues. Administering prophylactic antibiotics (B) is not indicated for preventing Candidiasis. Promoting nutrition and fluid intake (C) is important for overall health but does not directly address the risk of impaired skin integrity. Applying skin emollients (D) may help with skin dryness but does not directly address the underlying cause of Candidiasis.
Question 4 of 9
A woman aged 48 years comes to the clinic because she has discovered a lump in her breast. After diagnostic testing, the woman receives a diagnosis of breast cancer. The woman asks the nurse when her teenage daughters should begin mammography. What is the nurses best advice?
Correct Answer: D
Rationale: The correct answer is D: Age 48. This recommendation aligns with the current guidelines from major health organizations, such as the American Cancer Society, which suggest that women at average risk should start regular mammograms at age 45 to 54. Screening before age 45 may lead to unnecessary procedures due to false positives. Beginning at age 48 allows for early detection without subjecting the daughters to unnecessary testing at a younger age. Choices A, B, and C are incorrect as they suggest starting mammography at younger ages than recommended, which can increase the likelihood of false positives and unnecessary interventions.
Question 5 of 9
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
Correct Answer: C
Rationale: The correct answer is C because an older patient with glaucoma is at risk for increased intraocular pressure when receiving an enema. This situation requires immediate attention to prevent potential complications like vision loss. The other choices do not pose immediate risks that require urgent intervention. A and B can wait for a brief period, while D is not time-sensitive in the context of a myocardial infarction. The priority is always given to the patient with the highest risk of harm if the intervention is delayed.
Question 6 of 9
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
Correct Answer: B
Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention. Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B. Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B. Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.
Question 7 of 9
A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient?
Correct Answer: B
Rationale: The correct answer is B: Flex head with chin tuck. This position helps prevent aspiration by closing off the airway during swallowing. Flexing the head and tucking the chin promotes safe swallowing and reduces the risk of choking. Placing food on the left side (choice C) is not relevant to addressing the patient's symptoms. Positioning in semi-Fowler's (choice A) may not directly address the swallowing difficulty. Offering fruit juice (choice D) does not address the patient's specific feeding needs and may not be safe if the patient has swallowing difficulties.
Question 8 of 9
A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What is the nurse discussing?
Correct Answer: B
Rationale: The correct answer is B: Basal metabolic rate (BMR). BMR refers to the minimum amount of energy required to maintain basic physiological functions at rest. It accounts for about 60-75% of total energy expenditure. It is essential for sustaining life-sustaining activities such as breathing, circulating blood, and maintaining body temperature. Incorrect Choices: A: Resting energy expenditure (REE) is the total amount of energy expended by the body while at rest, including BMR and additional energy for daily activities. C: Nutrient density refers to the amount of nutrients per calorie in a food item, not the energy needed at rest. D: Nutrients are essential substances in food required for growth, maintenance, and repair, but they do not specifically refer to the energy needed at rest.
Question 9 of 9
The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?
Correct Answer: A
Rationale: The correct answer is A because measuring capillary blood glucose level is a task that can be safely delegated to nursing assistive personnel. This task is within their scope of practice and does not require specialized nursing knowledge. Nursing assistive personnel can perform this task accurately with proper training and supervision. Incorrect choices: B: Measuring nasoenteric tube for insertion requires specialized training and assessment skills that nursing assistive personnel may not possess. C: Measuring pH in gastrointestinal aspirate involves interpretation and clinical judgment that should be done by a licensed nurse. D: Measuring the patient's risk for aspiration involves critical thinking and assessment skills that are beyond the scope of nursing assistive personnel.