ATI RN
foundations of nursing test bank Questions
Question 1 of 5
The nurse is planning care for a group of patients.Which task will the nurse assign to the nursing assistive personnel (NAP)?
Correct Answer: C
Rationale: Correct Answer: C - Administering an enema Rationale: Administering an enema is a task that can be safely delegated to nursing assistive personnel (NAP) as it is within their scope of practice and does not require the specialized knowledge and skills of a registered nurse. NAP can be trained to perform enema administration safely and effectively, under the supervision of a nurse. This task involves following a specific procedure and does not require clinical judgment or decision-making. Summary of other choices: A: Performing the first postoperative pouch change - This task involves wound care and assessment, which require the expertise of a registered nurse. B: Maintaining a nasogastric tube - This task involves ongoing assessment, monitoring for complications, and adjustments, which are responsibilities of a registered nurse. D: Digitally removing stool - This task involves invasive procedures and assessment, which are beyond the scope of practice for nursing assistive personnel.
Question 2 of 5
A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
Correct Answer: B
Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction. Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.
Question 3 of 5
A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Serum albumin level. Serum albumin is an important indicator of nutritional status, as low levels may indicate malnutrition or inflammation commonly seen in AIDS patients. Weight history (B) is also relevant as weight changes can reflect nutritional status. White blood cell count (C) is not directly related to nutritional status. Body mass index (D) is a calculation based on weight and height, not a direct measure of nutritional status. Blood urea nitrogen (E) is a measure of kidney function, not a specific indicator of nutritional status. Therefore, the nurse should primarily focus on assessing the patient's serum albumin level for nutritional status evaluation in this case.
Question 4 of 5
Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?
Correct Answer: D
Rationale: Correct Answer: D Rationale: 1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis. 2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents. 3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications. Summary: A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario. B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident. C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.
Question 5 of 5
A patient has just been diagnosed with breast cancer and the nurse is performing a patient interview. In assessing this patients ability to cope with this diagnosis, what would be an appropriate question for the nurse to ask this patient?
Correct Answer: C
Rationale: The correct answer is C: Is there someone you trust to help you make treatment choices? This question assesses the patient's support system and ability to make informed decisions, which are crucial in coping with a breast cancer diagnosis. It shows the nurse's consideration for the patient's emotional well-being and involvement in the decision-making process. Choice A: What is your level of education? This question is not directly related to coping with the diagnosis of breast cancer and may not provide relevant information about the patient's ability to cope. Choice B: Are you feeling alright these days? While this question shows concern for the patient's well-being, it does not specifically address coping mechanisms or support systems. Choice D: Are you concerned about receiving this diagnosis? This question focuses on the patient's emotional reaction to the diagnosis but does not directly assess coping strategies or support systems.