ATI RN
foundation of nursing questions Questions
Question 1 of 9
The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching?
Correct Answer: D
Rationale: The correct answer is D: "Don't blow your nose for 2 to 3 weeks." After mastoid surgery, blowing the nose can increase pressure in the surgical area and disrupt healing. Here's the rationale: 1. Blowing the nose can increase pressure in the surgical area and lead to complications. 2. Avoiding blowing the nose helps prevent infection and reduces the risk of damaging the surgical site. 3. It is essential to follow this instruction to promote proper healing and reduce the chances of postoperative complications. In summary, the other choices are incorrect because inducing a sneeze, exercising, and avoiding side-lying position do not directly relate to the specific care needs after mastoid surgery.
Question 2 of 9
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.
Question 3 of 9
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement. Summary of Incorrect Choices: A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach. B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage. D: Measuring from the tip of the nose to the earlobe to
Question 4 of 9
The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk?
Correct Answer: A
Rationale: The correct answer is A: Providing thorough oral care before and after meals. This addresses the risk for impaired skin integrity related to Candidiasis in patients with stage 3 HIV by preventing oral Candidiasis, a common fungal infection. Poor oral hygiene can lead to Candidiasis, which can spread to the skin. Thorough oral care reduces the risk of oral Candidiasis, thereby preventing skin integrity issues. Administering prophylactic antibiotics (B) is not indicated for preventing Candidiasis. Promoting nutrition and fluid intake (C) is important for overall health but does not directly address the risk of impaired skin integrity. Applying skin emollients (D) may help with skin dryness but does not directly address the underlying cause of Candidiasis.
Question 5 of 9
A 62-year-old woman diagnosed with breast cancer is scheduled for a partial mastectomy. The oncology nurse explained that the surgeon will want to take tissue samples to ensure the disease has not spread to adjacent axillary lymph nodes. The patient has asked if she will have her lymph nodes dissected, like her mother did several years ago. What alternative to lymph node dissection will this patient most likely undergo?
Correct Answer: D
Rationale: The correct answer is D: Sentinel node biopsy. This procedure involves identifying and removing the sentinel lymph node(s) which is the first lymph node(s) that cancer cells are likely to spread to from the primary tumor. This method helps determine if cancer has spread beyond the primary site without the need for a full axillary lymph node dissection. It is less invasive, has fewer side effects, and provides accurate staging information. Lymphadenectomy (A) refers to the removal of multiple lymph nodes, which is more extensive than necessary in this case. Needle biopsy (B) and open biopsy (C) are not specific to lymph node evaluation and do not provide accurate staging information for breast cancer.
Question 6 of 9
A 30-year-old patient has come to the clinic for her yearly examination. The patient asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer?
Correct Answer: C
Rationale: Step 1: The nurse should inform the patient that most cases of ovarian cancer are considered to be random, with no obvious causation. This is the correct answer because the exact cause of ovarian cancer is not well understood, and the majority of cases are not linked to specific risk factors. Step 2: Choice A is incorrect because the use of oral contraceptives actually decreases the risk of ovarian cancer. Step 3: Choice B is incorrect because tobacco use is not a major risk factor for ovarian cancer. It is primarily associated with lung and other types of cancer. Step 4: Choice D is incorrect because while a family history of ovarian cancer can increase the risk, the majority of women diagnosed with ovarian cancer do not have a family history of the disease.
Question 7 of 9
A nurse is providing care to a patient from adifferent culture. Which action by the nurse indicates cultural competence?
Correct Answer: A
Rationale: The correct answer is A because effective communication in a multicultural context is essential for cultural competence. By communicating effectively, the nurse can understand and respect the patient's cultural beliefs, values, and practices. This helps in providing appropriate care tailored to the patient's cultural needs. Choice B is too vague and does not specifically address communication skills. Choice C, visiting a foreign country, does not directly demonstrate cultural competence in patient care. Choice D, speaking a different language, is important but not sufficient on its own to indicate cultural competence without effective communication skills.
Question 8 of 9
A patient with Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this patient. Nutritional management for a patient with Huntington disease should be informed by what principle?
Correct Answer: D
Rationale: The correct answer is D - The patient will benefit from a low-protein diet. Patients with Huntington disease often experience difficulty swallowing and may have involuntary movements, leading to weight loss. A low-protein diet can help manage these symptoms and reduce the risk of aspiration pneumonia. This diet can also help control the chorea movements associated with the disease. Choice A is incorrect as patients with Huntington disease often have reduced appetite due to swallowing difficulties. Choice B is incorrect as enzyme supplements are not typically indicated in the management of Huntington disease. Choice C is incorrect as a clear liquid diet is not suitable for meeting the nutritional needs of a patient with Huntington disease, who may already be at risk for malnutrition.
Question 9 of 9
Anti-infective prophylaxis is indicated for a pregnant patient with a history of mitral valve stenosis related to rheumatic heart disease because the patient is at risk of developing
Correct Answer: C
Rationale: The correct answer is C: bacterial endocarditis. Mitral valve stenosis increases the risk of bacterial endocarditis due to turbulent blood flow and potential damage to the heart valve. Prophylactic antibiotics are recommended before certain procedures to prevent bacterial endocarditis in patients with underlying cardiac conditions. Choice A, hypertension, is incorrect as mitral valve stenosis does not directly increase the risk of developing hypertension. Choice B, postpartum infection, is not directly related to the risk associated with mitral valve stenosis. Choice D, upper respiratory infections, is not a specific risk associated with mitral valve stenosis in pregnant patients.