ATI RN
test bank foundations of nursing Questions
Question 1 of 9
The nurse is caring for a patient of Hispanicdescent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Look at the patient when talking. This is important because maintaining eye contact shows respect, builds trust, and enhances communication with the patient. By looking at the patient, the nurse can also observe nonverbal cues and ensure the patient is engaged in the conversation. Choice A: Using long sentences can be overwhelming for a patient who may not understand the language, leading to miscommunication. Choice C: Using breaks in sentences may help the interpreter better convey the message, but looking at the patient is more essential for effective communication. Choice D: Looking at only nonverbal behaviors neglects the importance of eye contact and direct communication with the patient.
Question 2 of 9
A nurse in a long-term care setting that is fundedby Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?
Correct Answer: A
Rationale: The correct answer is A: A minimum data set. In a long-term care setting funded by Medicare and Medicaid, completing standardized protocols for assessment and care planning for reimbursement involves using a minimum data set, which is a standardized instrument for assessing residents' health status. This set of data elements is necessary for comprehensive assessment and care planning to ensure appropriate reimbursement. The other choices (B, C, D) do not specifically address the standardized protocols required for reimbursement in this setting. An admission assessment and acuity level would be part of the process, but not the primary task being completed in this scenario. A focused assessment on a specific body system or an intake assessment form and auditing phase are not synonymous with the standardized protocols needed for reimbursement in a Medicare/Medicaid-funded long-term care facility.
Question 3 of 9
A nurse is caring for a patient who just underwentan intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse’sfirstpriorityin caring for this patient?
Correct Answer: C
Rationale: The correct answer is C: Monitor the patient for fever, rash, and difficulty breathing. The rationale is as follows: 1. Renal calculus obstruction can lead to complications such as infection, so monitoring for fever is crucial. 2. Rash can indicate an allergic reaction to the contrast dye used in the procedure. 3. Difficulty breathing may signal a severe reaction or complications. Summary: A: Turning the patient on the right side does not directly address the urgent need to monitor for potential complications. B: While fluid intake is important, it is not the immediate priority when the patient is at risk of developing complications. D: Administering narcotic medications may be necessary for pain relief but does not address the potential emergent issues related to the obstruction.
Question 4 of 9
A child is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. What food items would the nurse inform the parents are common allergens?
Correct Answer: C
Rationale: The correct answer is C: Eggs and wheat. This is because eggs and wheat are common food allergens in children. Eggs contain proteins that can trigger allergic reactions, while wheat contains gluten, a common allergen. Citrus fruits and rice (choice A) are not common allergens. Root vegetables and tomatoes (choice B) are also less likely to cause allergies. Hard cheeses and vegetable oils (choice D) are not commonly associated with food allergies in children. Therefore, informing the parents about eggs and wheat as common allergens is crucial for the child's testing and management of food allergies.
Question 5 of 9
A nurse is describing the purposes of a healthcare record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all thatapply.)
Correct Answer: A
Rationale: The correct answer is A: Communication. Healthcare records are essential for effective communication among healthcare providers to ensure continuity of care. They help convey important information about a patient's condition, treatment plan, and progress. Explanation: 1. Communication: Healthcare records facilitate communication between different healthcare team members, ensuring coordinated and efficient care delivery. 2. Legal documentation: While important, legal documentation is a separate purpose of healthcare records, not directly related to communication. 3. Reimbursement: Healthcare records are used for billing and reimbursement purposes, but this is not directly related to communication. 4. Nursing process: The nursing process involves assessment, diagnosis, planning, implementation, and evaluation of patient care, which is documented in healthcare records. However, this is not a primary purpose related to communication.
Question 6 of 9
During a recent visit to the clinic a woman presents with erythema of the nipple and areola on the right breast. She states this started several weeks ago and she was fearful of what would be found. The nurse should promptly refer the patient to her primary care provider because the patients signs and symptoms are suggestive of what health problem?
Correct Answer: C
Rationale: Rationale: 1. Erythema of nipple/areola in one breast can be a sign of Paget's disease, a rare form of breast cancer. 2. Paget's disease may also present with itching, tingling, or a burning sensation in the affected area. 3. Referring the patient promptly is crucial for early detection and appropriate management. 4. Peau d'orange (A) is a sign of advanced breast cancer, not typically presenting with erythema alone. 5. Nipple inversion (B) may be benign or related to other conditions, not typically presenting with erythema. 6. Acute mastitis (D) presents with breast pain, warmth, swelling, and fever, but not typically with isolated erythema of the nipple/areola.
Question 7 of 9
A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching?
Correct Answer: A
Rationale: Correct Answer: A - Care of the cervical collar Rationale: 1. Care of the cervical collar is essential post-cervical diskectomy to ensure proper immobilization and support. 2. Proper care prevents complications and promotes healing. 3. It is a crucial aspect of discharge education to prevent injury and promote recovery. Summary of other choices: B: Technique for performing neck ROM exercises - Important for rehabilitation but not directly related to discharge education post-cervical diskectomy. C: Home assessment of ABGs - Irrelevant to post-cervical diskectomy discharge education. D: Techniques for restoring nerve function - Important for recovery but not a primary focus of discharge education.
Question 8 of 9
A patient with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education?
Correct Answer: B
Rationale: The correct answer is B: Importance of personal hygiene. Maintaining good personal hygiene is crucial for patients with HIV to prevent infections. This includes regular handwashing, oral care, and bathing. By emphasizing personal hygiene, the nurse can help the patient reduce the risk of opportunistic infections. Prophylactic antibiotics (choice A) are important but should be prescribed by the healthcare provider. Signs and symptoms of wasting syndrome (choice C) are significant, but focusing on prevention through hygiene is more practical. Adjusting antiretroviral dosages (choice D) is the responsibility of the healthcare provider, not the patient.
Question 9 of 9
A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
Correct Answer: A
Rationale: The correct answer is A: Perianal region and oral mucosa. In patients with AIDS, these areas are more prone to opportunistic infections due to decreased immune function. The perianal region can be affected by conditions like anal warts or herpes, while the oral mucosa can develop oral thrush or other oral infections. By prioritizing assessment of these areas, the nurse can promptly identify any potential issues and initiate appropriate interventions. Choice B: Sacral region and lower abdomen are not typically high-risk areas for skin integrity issues in AIDS patients. Choice C: Scalp and skin over the scapulae are not commonly affected by opportunistic infections related to AIDS. Choice D: Axillae and upper thorax are not as commonly affected as the perianal region and oral mucosa in AIDS patients.