ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patients care?
Correct Answer: C
Rationale: The correct answer is C: Risk for falls. Patients with vertigo experience a false sensation of spinning or movement, which can lead to imbalance and increased risk of falls. Prioritizing the risk for falls is crucial to prevent injuries and ensure patient safety. Other choices are incorrect as they do not directly address the immediate safety concern of falls associated with vertigo. A: Risk for disturbed sensory perception may be present, but the priority is preventing falls. B: Risk for unilateral neglect is not typically associated with vertigo. D: Risk for ineffective health maintenance is important but falls take precedence due to the immediate risk of injury.
Question 2 of 9
The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?
Correct Answer: A
Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely
Question 3 of 9
A patient with end-stage heart failure has participated in a family meeting with the interdisciplinary team and opted for hospice care. On what belief should the patients care in this setting be based
Correct Answer: C
Rationale: The correct answer is C: Meaningful living during terminal illness is best supported in the home. This is because hospice care focuses on providing compassionate care and support in the comfort of the patient's own home, which can enhance quality of life and dignity. Being in a familiar and comfortable environment allows the patient to receive personalized care and emotional support from family members. Options A, B, and D are incorrect because hospice care emphasizes comfort and quality of life over technologic interventions, designated facilities, and prolonging physiologic dying. Ultimately, the goal of hospice care is to prioritize the patient's emotional and physical well-being during the end stages of life.
Question 4 of 9
A patient has sought care, stating that she developed hives overnight. The nurses inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed?
Correct Answer: A
Rationale: The correct answer is A: Type I hypersensitivity reaction. This type of reaction involves the release of histamine from mast cells and basophils, leading to symptoms like hives. It is characterized by the involvement of IgE antibodies. In this case, the patient developed hives quickly after exposure to the allergen, indicating an immediate hypersensitivity reaction typical of Type I. Choices B, C, and D are incorrect because they are associated with different mechanisms and timeframes of hypersensitivity reactions. Type II involves antibody-mediated cell destruction, Type III involves immune complex deposition, and Type IV is a delayed-type hypersensitivity reaction mediated by T cells, none of which are consistent with the rapid onset of hives seen in this patient.
Question 5 of 9
The nurse is orienting a new nurse to the oncology unit. When reviewing the safe administration of antineoplastic agents, what action should the nurse emphasize?
Correct Answer: D
Rationale: The correct answer is D: Dispose of the antineoplastic wastes in the hazardous waste receptacle. This is crucial to prevent exposure to potentially harmful substances. Here's the rationale: 1. Antineoplastic agents are hazardous chemicals that can harm individuals and the environment. 2. Proper disposal in a hazardous waste receptacle ensures safety and compliance with regulations. 3. Options A, B, and C are incorrect as adjusting doses based on symptoms, hand hygiene, and personal protective equipment are important but not as critical as proper disposal of hazardous waste in this context.
Question 6 of 9
In which situation would a dilation and curettage (D&C) be indicated?
Correct Answer: B
Rationale: The correct answer is B because an incomplete abortion at 16 weeks may require a D&C to remove remaining tissue to prevent infection and complications. Incomplete abortion means not all fetal tissue has been expelled, posing a risk. Choice A (complete abortion at 8 weeks) does not require a D&C as all tissue is expelled. Choice C (threatened abortion at 6 weeks) does not necessitate immediate intervention. Choice D (incomplete abortion at 10 weeks) is not the best choice as the risk of complications increases with gestational age.
Question 7 of 9
The nurses assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patients visual acuity?
Correct Answer: B
Rationale: The correct answer is B because the patient's inability to count fingers indicates severe visual impairment. Testing hand motion perception is a more appropriate initial assessment for patients with such significant visual losses. This method can differentiate between light perception and no light perception, providing valuable information about the patient's visual acuity. The other choices are incorrect because assessing vision using a Snellen chart (A) requires more visual acuity than just being able to see hand motion. Performing a detailed examination of external eye structures (C) and palpating periocular regions (D) are not relevant for assessing visual acuity and do not provide information on the patient's ability to perceive hand motion.
Question 8 of 9
The nurse is planning health education for a patient who has experienced a vaginal infection. What guidelines should the nurse include in this program regarding prevention?
Correct Answer: C
Rationale: The correct answer is C: Avoid feminine hygiene products, such as sprays. This is because feminine hygiene products can disrupt the natural balance of vaginal flora, leading to an increased risk of vaginal infections. Tight-fitting synthetic underwear (choice A) can trap moisture and promote bacterial growth. Using bubble bath (choice B) can irritate the genital area and disrupt the pH balance. Restricting daily bathing (choice D) is not recommended as regular hygiene practices are important for preventing infections. In summary, choice C is correct as it promotes maintaining the natural vaginal flora and pH balance to prevent infections, while the other choices can contribute to an increased risk of vaginal infections.
Question 9 of 9
The nurse is using different toileting schedules.Which principles will the nurse keep in mind when planning care? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A because habit training involves keeping a bladder diary to identify patterns and develop a toileting schedule. This helps in promoting regular voiding habits. B is incorrect because timed voiding isn't solely based on the patient's urge to void, but rather on a predetermined schedule. C is incorrect as prompted voiding involves reminding patients to use the restroom at regular intervals, not just asking if they are wet or dry. D is incorrect because elevating feet in patients with edema may help reduce swelling but has no direct impact on nighttime voiding.