ATI RN
foundation of nursing practice questions Questions
Question 1 of 5
The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement?
Correct Answer: B
Rationale: After a mastoidectomy, the ear should be protected from water for several weeks. This is because exposing the area to water can increase the risk of infection. Keeping the ear dry allows the surgical site to heal properly and reduces the likelihood of postoperative complications such as infection. Therefore, instructing the patient to protect the ear from water is an important intervention to prevent postoperative infection following a mastoidectomy.
Question 2 of 5
The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid?
Correct Answer: A
Rationale: Trigeminal neuralgia is a condition characterized by severe facial pain due to irritation or damage to the trigeminal nerve. Factors such as touching or lightly brushing the face, chewing, speaking, or even encountering a breeze can trigger an attack. Therefore, activities like washing the face that involve touching or stimulating the trigeminal nerve can precipitate an attack in patients with trigeminal neuralgia. It is important for patients to be aware of these triggers to help manage and prevent episodes of pain.
Question 3 of 5
A nurse is assessing a patient with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment?
Correct Answer: A
Rationale: A nurse assessing a patient with an acoustic neuroma would likely find symptoms such as loss of hearing, tinnitus, and vertigo. Acoustic neuroma, also known as vestibular schwannoma, is a noncancerous tumor that develops on the vestibulocochlear nerve, which carries sound and balance signals from the inner ear to the brain. The most common symptoms of an acoustic neuroma include progressive hearing loss, ringing in the ears (tinnitus), and dizziness or imbalance (vertigo). Therefore, option A is the most appropriate choice for the symptoms that the nurse is likely to find in a patient with an acoustic neuroma.
Question 4 of 5
While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurses most appropriate action?
Correct Answer: B
Rationale: The most appropriate action for the nurse to take when observing the surgical dressing saturated with serosanguineous drainage is to reinforce the dressing and reassess in 1 to 2 hours. Serosanguineous discharge is a common type of drainage following surgery, as it is a mixture of blood and serum. It is expected in the early stages of wound healing and does not necessarily indicate infection. By reinforcing the dressing and closely monitoring the drainage over the next couple of hours, the nurse can assess if the amount of drainage is decreasing or escalating. If there are any signs of infection, such as increasing redness, warmth, swelling, or excessive purulent discharge, then the nurse should notify the physician promptly. Until then, it is appropriate to continue observing and managing the drainage within the expected range.
Question 5 of 5
A male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first?
Correct Answer: D
Rationale: When a patient is experiencing a seizure and begins vomiting, the priority action for the nurse is to turn the patient onto their side. This position helps to prevent aspiration, which can occur when the patient inhales vomit into their lungs. Turning the patient on their side allows for the vomit to drain out of the mouth, reducing the risk of aspiration and maintaining a clear airway. Performing oral suctioning would be necessary after turning the patient on their side, but it is not the initial priority in this situation. Paging the physician and inserting a tongue depressor are not appropriate actions during a seizure and vomiting episode.