ATI RN
foundation of nursing practice questions Questions
Question 1 of 9
The nurse is caring for a patient who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the patients death is imminent?
Correct Answer: A
Rationale: Mottling of the lower limbs is a common physical sign seen in patients approaching death. This occurs when there is poor circulation leading to a bluish or purplish discoloration of the skin, particularly on the extremities. The appearance of mottling indicates that the body is no longer able to maintain adequate blood flow to the extremities, signaling that the patient is in the final stages of life. It is a significant finding that strongly suggests imminent death in patients with terminal illness, such as in this case of a patient with terminal lung cancer who is unconscious.
Question 2 of 9
A nurse needs to begin discharge planning fora patient admitted with pneumonia and a congested cough. When is the besttime the nurse should start discharge planningfor this patient?
Correct Answer: A
Rationale: The best time for a nurse to start discharge planning for a patient admitted with pneumonia and a congested cough is upon admission. Starting discharge planning early allows the healthcare team to identify the patient's needs, plan for the appropriate level of care, and ensure a smooth transition out of the hospital. Waiting until right before discharge or after the congestion is treated may lead to rushed or incomplete planning, potentially compromising the patient's recovery and post-discharge care. Additionally, discharge planning is not dependent on the primary care provider writing an order, as nurses can initiate teaching and planning proactively to support the patient's optimal recovery and transition. By beginning discharge planning upon admission, the healthcare team can address any potential barriers to discharge and ensure the patient's needs are met for a successful recovery process.
Question 3 of 9
The nurse is caring for a patient who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the patients death is imminent?
Correct Answer: A
Rationale: Mottling of the lower limbs is a common physical sign seen in patients approaching death. This occurs when there is poor circulation leading to a bluish or purplish discoloration of the skin, particularly on the extremities. The appearance of mottling indicates that the body is no longer able to maintain adequate blood flow to the extremities, signaling that the patient is in the final stages of life. It is a significant finding that strongly suggests imminent death in patients with terminal illness, such as in this case of a patient with terminal lung cancer who is unconscious.
Question 4 of 9
A patient has presented at the clinic with symptoms of benign prostatic hyperplasia. What diagnostic findings would suggest that this patient has chronic urinary retention?
Correct Answer: D
Rationale: Chronic urinary retention can lead to an elevated blood urea nitrogen (BUN) level due to impaired kidney function. When urine is not effectively eliminated from the body, waste products, including urea, accumulate in the bloodstream. This can result in an increase in BUN levels, indicating potential kidney dysfunction in the setting of chronic urinary retention. Hypertension (Choice A), peripheral edema (Choice B), and tachycardia and other dysrhythmias (Choice C) are not specifically associated with chronic urinary retention but may be related to other conditions or comorbidities.
Question 5 of 9
The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take?
Correct Answer: D
Rationale: When caring for a patient receiving total parenteral nutrition (TPN), it is crucial to maintain strict aseptic technique to prevent infection. Wearing a sterile mask when changing the central venous catheter dressing helps to reduce the risk of introducing pathogens into the catheter site, which can lead to serious bloodstream infections. It is essential to use sterile gloves, a sterile mask, and to assess the insertion site for any signs or symptoms of infection during central venous catheter dressing changes. Additionally, to prevent infection, TPN infusion tubing should be changed every 24 hours, and no single container of TPN should be hung for longer than 24 hours, with lipids not running for longer than 12 hours.
Question 6 of 9
The nurse responds to the call light of a patient who has had a cervical diskectomy earlier in the day. Thecpatient states that she is having severe pain that had a sudden onset. What is the nurses most appropriate action?
Correct Answer: C
Rationale: In this scenario, the patient who has had a cervical diskectomy is experiencing severe pain with a sudden onset, which can be indicative of a complication such as bleeding, infection, or nerve impingement. The nurse's most appropriate action is to call the surgeon immediately to report the patient's pain. The surgeon needs to be informed promptly so that a further assessment can be made and appropriate interventions can be initiated to address the cause of the sudden pain. Palpating the surgical site or removing the dressing without consulting the surgeon first may worsen the situation or increase the risk of complications. Administering an NSAID is not appropriate in this situation without further evaluation and guidance from the surgeon. It is essential to prioritize patient safety and ensure that the patient receives timely and appropriate care by involving the surgeon in the decision-making process.
Question 7 of 9
A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the patients room?
Correct Answer: B
Rationale: It is crucial for the nurse to monitor that all furniture remains in the same position in the hospitalized patient's room. For a patient with impaired vision who needs to create a mental picture of the room to mobilize independently and safely, any changes in the position of furniture can disrupt this mental map and potentially lead to accidents or falls. By ensuring that all furniture remains unchanged, the nurse supports the patient's ability to navigate the room confidently and without obstacles. This monitoring helps promote the patient's safety and independence during their stay in the hospital.
Question 8 of 9
The nurse is describing theChooseMyPlateprogramto a patient. Which statement from the patient indicates successful learning?
Correct Answer: A
Rationale: This statement indicates successful learning because it acknowledges the main purpose of the ChooseMyPlate program, which is to help individuals make healthy food choices for a balanced diet and overall lifestyle. By understanding that ChooseMyPlate can guide them in making healthier food choices rather than just counting calories or using it for specific circumstances like sickness or infant care, the patient demonstrates a good grasp of the program's intended use and benefits.
Question 9 of 9
A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is most appropriate?
Correct Answer: D
Rationale: Blurred vision is a common adverse effect of pilocarpine, a miotic agent commonly used for open-angle glaucoma. It occurs due to the constriction of the pupil, which can affect the patient's ability to focus clearly. Therefore, it is important for the nurse to explain to the patient that blurred vision is an expected adverse effect of the medication. This reassurance can help alleviate the patient's concerns and improve their understanding of the medication therapy. Holding the next dose and notifying the physician is not necessary in this situation as blurred vision is a known side effect and treating the patient for an allergic reaction or suggesting that the patient put on her glasses would not address the underlying cause of the blurred vision.