ATI RN
foundation of nursing questions Questions
Question 1 of 5
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action?
Correct Answer: C
Rationale: The correct answer is C: Place the patient on respiratory isolation and inform the physician. This is the most appropriate action because the patient is exhibiting symptoms that could be indicative of a potentially infectious respiratory condition, such as tuberculosis or pneumonia. Placing the patient on respiratory isolation helps prevent the spread of infection to others and protects healthcare workers. Informing the physician promptly allows for further evaluation and appropriate treatment. Choice A is incorrect as Kaposi's sarcoma typically presents with skin lesions rather than respiratory symptoms. Choice B is incorrect as reviewing viral load and CD4+ count would not address the immediate concern of respiratory symptoms. Choice D is incorrect as oral suctioning is not the appropriate intervention for night sweats and coughing up blood.
Question 2 of 5
A patient is learning about his new diagnosis of asthma with the asthma nurse. What medication has the ability to prevent the onset of acute asthma exacerbations?
Correct Answer: B
Rationale: The correct answer is B: Montelukast (Singulair). Montelukast is a leukotriene receptor antagonist that helps prevent asthma exacerbations by reducing inflammation in the airways. It is used as a maintenance medication to control and prevent asthma symptoms. Diphenhydramine (A) is an antihistamine used for allergies, not asthma prevention. Albuterol sulfate (C) is a rescue inhaler used for acute asthma symptoms, not prevention. Epinephrine (D) is used for severe allergic reactions (anaphylaxis), not asthma prevention.
Question 3 of 5
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
Correct Answer: B
Rationale: The correct answer is B: Thigh. When administering epinephrine during an anaphylactic reaction, the thigh is the recommended site due to its large muscle mass and quick absorption rate. Steps: 1. Remove safety cap. 2. Firmly push the auto-injector against the thigh until it clicks. 3. Hold in place for a few seconds. 4. Seek medical help immediately. Rationale for incorrect choices: A: Forearm - Not recommended due to smaller muscle mass and slower absorption. C: Deltoid muscle - Not preferred as it may not provide as rapid absorption as the thigh. D: Abdomen - Not ideal due to potential fat layers that could affect absorption speed.
Question 4 of 5
A nurse is aware of the need to assess patients risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis?
Correct Answer: C
Rationale: The correct answer is C: Computed tomography with contrast solution. This procedure involves the use of contrast agents that can trigger anaphylaxis due to the patient's allergic reaction to the contrast solution. Contrast solutions contain substances like iodine, which can cause severe allergic reactions in some individuals. Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and requires immediate intervention. Assessing the risk for anaphylaxis during this procedure is crucial to prevent any potential harm to the patient. Incorrect choices: A: Administration of the measles-mumps-rubella (MMR) vaccine - While allergic reactions can occur with vaccines, the risk of anaphylaxis with MMR vaccine is lower compared to the contrast solution used in CT scans. B: Rapid administration of intravenous fluids - Rapid IV fluid administration can cause fluid overload or electrolyte imbalances, but it is not typically associated with triggering anaphylaxis. D: Administration of nebulized bronchodil
Question 5 of 5
A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patients condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Foods. Anaphylaxis is a severe allergic reaction that can be triggered by foods, medications, insect stings, and other allergens. In this scenario, assessing for potential food allergies is crucial as food is one of the most common triggers for anaphylaxis. Foods like nuts, shellfish, and eggs are common culprits. Medications and insect stings (choices B and C) are also important triggers to consider in the assessment. Autoimmunity (choice D) is not a direct cause of anaphylaxis, as it involves the immune system attacking the body's own tissues rather than reacting to external allergens. Environmental pollutants (choice E) may trigger respiratory symptoms but are not typically associated with anaphylaxis.