ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient, what characteristic symptom would the nurse expect to find?
Correct Answer: A
Rationale: Step-by-step rationale for why A is correct: 1. Retinal detachment causes traction on the retina. 2. Traction on the retina can stimulate photoreceptors. 3. Stimulation of photoreceptors can lead to perception of flashing lights. 4. Therefore, the characteristic symptom of retinal detachment is flashing lights in the visual field. Summary: B: Sudden eye pain is not a characteristic symptom of retinal detachment. C: Loss of color vision is not typically associated with retinal detachment. D: Colored halos around lights are more indicative of conditions like glaucoma or corneal edema, not retinal detachment.
Question 2 of 9
Massage around the feces and work down to remove.
Correct Answer: A
Rationale: The correct order for the massage is to start around the feces (4), then work downwards (1), followed by moving towards the sides (5), then back to the top (2), continuing to the sides again (3), and finally finishing at the top (6). This sequence ensures a thorough and effective massage process. Other choices have different orders that do not follow the logical flow of massaging around the feces and working down as specified in the question.
Question 3 of 9
A patient has experienced occasional urinary incontinence in the weeks since his prostatectomy. In order to promote continence, the nurse should encourage which of the following?
Correct Answer: A
Rationale: The correct answer is A: Pelvic floor exercises. Pelvic floor exercises help strengthen the muscles that control urination, promoting continence. These exercises can improve bladder control and reduce urinary incontinence post-prostatectomy. Intermittent urinary catheterization (B) may lead to increased risk of infection. Reduced physical activity (C) can weaken pelvic floor muscles, worsening incontinence. Active range of motion exercises (D) do not directly address urinary incontinence.
Question 4 of 9
A patient is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the patients statements best demonstrates an adequate understanding?
Correct Answer: D
Rationale: The correct answer is D: "I need to call the doctor if I see flashing lights." This is because seeing flashing lights after cataract extraction with intraocular lens implant can be a sign of a serious complication like retinal detachment. Prompt reporting is crucial to prevent vision loss. Choice A is incorrect because nausea is not typically a sign of a complication related to cataract surgery. Choice B is also incorrect as a light morning discharge is normal post-surgery unless it's excessive or associated with pain or visual changes. Choice C is incorrect as a scratchy feeling is common after surgery and usually resolves on its own.
Question 5 of 9
Which action indicates the nurse is meeting aprimary goal of cultural competent care for patients?
Correct Answer: C
Rationale: The correct answer is C because providing individualized care is a fundamental aspect of cultural competence. This means tailoring care to meet the unique cultural, social, and personal needs of each patient. It involves understanding and respecting a patient's beliefs, values, and practices. Explanation: A. Providing care to transgender patients is important, but it is not the primary goal of cultural competence. B. Restoring relationships is beneficial but may not directly address cultural competence. D. Providing care to surgical patients is a common nursing duty but does not specifically relate to cultural competence.
Question 6 of 9
A nurse is performing an assessment on a patientwho has not had a bowel movement in 3 days. The nurse will expect which other assessment finding?
Correct Answer: A
Rationale: The correct answer is A: Hypoactive bowel sounds. When a patient has not had a bowel movement in 3 days, it indicates constipation. Constipation can lead to decreased peristalsis, resulting in hypoactive bowel sounds. Increased fluid intake (B) would be a potential intervention, not an expected assessment finding. A soft tender abdomen (C) may indicate other issues like inflammation or infection, not directly related to constipation. Jaundice in the sclera (D) is indicative of liver dysfunction, not a typical finding associated with constipation.
Question 7 of 9
A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will present with what alteration in laboratory values?
Correct Answer: A
Rationale: The correct answer is A: Increased eosinophils. Eosinophils are a type of white blood cell involved in allergic reactions. During anaphylaxis, the body releases chemicals that stimulate the production and activation of eosinophils, leading to an increase in their count. This helps in the identification of an allergic reaction. Incorrect Choices: B: Increased neutrophils - Neutrophils are not specific to allergic reactions and are typically increased in bacterial infections. C: Increased serum albumin - Serum albumin levels are not directly affected by allergic reactions. D: Decreased blood glucose - Hypoglycemia is not a typical manifestation of an allergic reaction.
Question 8 of 9
The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads in the electronic health record that the patient has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem?
Correct Answer: B
Rationale: The correct answer is B: Impaired wound healing. Radiation therapy can lead to damage to the skin and blood vessels, affecting wound healing. The nurse should prioritize assessing the patient's skin integrity and any signs of impaired wound healing to prevent complications post-surgery. A: Cognitive deficits - While radiation therapy can impact cognitive function in some cases, it is not the most immediate concern related to surgery post-radiation therapy. C: Cardiac tamponade - Although radiation therapy can increase the risk of heart-related issues, such as pericarditis, cardiac tamponade is a rare and acute complication that is not the most likely immediate concern post-radiation therapy. D: Tumor lysis syndrome - This syndrome is more commonly seen in patients undergoing chemotherapy rather than radiation therapy. It is not typically a concern immediately post-radiation therapy.
Question 9 of 9
A patient with low vision has called the clinic and asked the nurse for help with acquiring some lowvision aids. What else can the nurse offer to help this patient manage his low vision?
Correct Answer: C
Rationale: The correct answer is C: The patient has diabetes. Diabetes can lead to diabetic retinopathy, a common cause of low vision. By knowing the patient's medical history, the nurse can recommend appropriate low vision aids and refer the patient to an ophthalmologist for further evaluation and management. Incorrect choices: A: The patient uses OTC NSAIDs - NSAIDs are not relevant to managing low vision. B: The patient has a history of stroke - A history of stroke is not directly related to low vision. D: The patient has Asian ancestry - Ancestry is not a factor in managing low vision.