ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction?
Correct Answer: A
Rationale: The correct answer is A: Anaphylactic reaction after a bee sting. Type I hypersensitivity reactions involve an immediate response triggered by exposure to an allergen, leading to the release of histamine and other inflammatory mediators. In this case, a bee sting would introduce an allergen, causing a rapid and severe systemic reaction, known as anaphylaxis. B: Skin reaction resulting from adhesive tape is an example of a Type IV hypersensitivity reaction, mediated by T cells, not IgE antibodies as in Type I reactions. C: Myasthenia gravis is an autoimmune disorder involving antibodies attacking acetylcholine receptors, not a Type I hypersensitivity reaction. D: Rheumatoid arthritis is an autoimmune disorder involving immune complexes and inflammatory responses, not a Type I hypersensitivity reaction.
Question 2 of 9
A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication?
Correct Answer: A
Rationale: The correct answer is A: HIV encephalopathy. This condition, also known as AIDS dementia complex, is characterized by progressive decline in cognitive, behavioral, and motor functions due to HIV affecting the brain. The onset of these symptoms in the patient is indicative of HIV encephalopathy. Explanation for why other choices are incorrect: B: B-cell lymphoma is a type of cancer that can occur in patients with AIDS, but it typically presents with symptoms related to lymph nodes or other organs, not cognitive decline. C: Kaposis sarcoma is a type of cancer caused by the human herpesvirus 8, and it typically presents with skin lesions or internal organ involvement, not cognitive decline. D: Wasting syndrome is characterized by severe weight loss, weakness, and loss of muscle mass, but it does not directly cause cognitive, behavioral, and motor decline as seen in HIV encephalopathy.
Question 3 of 9
A new mother who is breastfeeding calls the clinic to speak to a nurse. The patient is complaining of pain in her left breast and describes her breast as feeling doughy. The nurse tells her to come into the clinic and be checked. The patient is diagnosed with acute mastitis and placed on antibiotics. What comfort measure should the nurse recommend?
Correct Answer: D
Rationale: The correct answer is D: Perform gentle massage to stimulate neutrophil migration. Gentle massage helps to promote drainage of the infected area by stimulating neutrophil migration, which aids in fighting the infection. This can help alleviate the pain and discomfort associated with acute mastitis. Cold compresses (choice A) may provide some relief, but they do not address the underlying issue of promoting neutrophil migration. Avoiding washing the breasts (choice C) is not recommended as maintaining good hygiene is important in preventing further infections. Avoiding wearing a bra (choice B) may not directly address the infection and may not be practical for the patient's daily activities.
Question 4 of 9
A patient is experiencing oliguria. Which actionshould the nurse performfirst?
Correct Answer: A
Rationale: The correct answer is A: Assess for bladder distention. Oliguria indicates decreased urine output, which could be due to urinary retention. Assessing for bladder distention helps identify the underlying cause. Requesting diuretics (B) without assessing first is premature. Increasing IV fluid rate (C) may worsen the situation if there is urinary retention. Encouraging caffeinated beverages (D) is not appropriate as they can worsen dehydration.
Question 5 of 9
A patients most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and liver. What is the most likely mechanism by which the patients cancer cells spread?
Correct Answer: A
Rationale: The correct answer is A: Hematologic spread. In this case, the cancer cells have traveled through the bloodstream to reach the bones and liver. This process is known as hematologic spread, where cancer cells enter the blood vessels and spread to distant organs. Lymphatic circulation (B) involves the spread of cancer cells through the lymphatic system, which is less likely in this scenario. Invasion (C) refers to cancer cells infiltrating nearby tissues, not distant organs. Angiogenesis (D) is the process of new blood vessel formation to support tumor growth, but it does not explain the spread of cancer cells to other organs.
Question 6 of 9
Which postpartum patient reqNuUirResS fuIrNthGerT aBss.esCsmOeMnt?
Correct Answer: A
Rationale: The correct answer is A because the postpartum patient who has had four saturated pads during the last 12 hours should receive further assessment. This indicates excessive postpartum bleeding (postpartum hemorrhage), which is a critical complication that requires immediate intervention to prevent complications like hypovolemic shock. Monitoring vital signs, assessing for signs of shock, evaluating uterine tone, and determining the cause of bleeding are crucial steps in managing postpartum hemorrhage. Choices B, C, and D are not the correct answers because: B: A patient with Class II heart disease complaining of frequent coughing is more likely experiencing cardiac-related issues and requires evaluation and management by a cardiologist. C: A patient with gestational diabetes and a fasting blood sugar level of 100 mg/dL is within the normal range and does not require immediate further assessment. D: A postcesarean patient with active herpes lesions on the labia requires appropriate management of the herpes infection but does not necess
Question 7 of 9
A patient with low vision has called the clinic and asked the nurse for help with acquiring some lowvision aids. What else can the nurse offer to help this patient manage his low vision?
Correct Answer: C
Rationale: The correct answer is C: The patient has diabetes. Diabetes can lead to diabetic retinopathy, a common cause of low vision. By knowing the patient's medical history, the nurse can recommend appropriate low vision aids and refer the patient to an ophthalmologist for further evaluation and management. Incorrect choices: A: The patient uses OTC NSAIDs - NSAIDs are not relevant to managing low vision. B: The patient has a history of stroke - A history of stroke is not directly related to low vision. D: The patient has Asian ancestry - Ancestry is not a factor in managing low vision.
Question 8 of 9
For which of the following population groups would an annual clinical breast examination be recommended?
Correct Answer: C
Rationale: The correct answer is C: Women over age 40. Annual clinical breast examinations are recommended for this population group because they have an increased risk of developing breast cancer compared to younger age groups. Regular screenings starting at age 40 can help in early detection and improve survival rates. A: Women over age 21 - This age group is generally recommended to start clinical breast examinations every 1-3 years, not necessarily annually. B: Women over age 25 - While it's important to be vigilant about breast health, the risk of breast cancer increases with age, making annual exams more crucial for older women. D: All post-pubescent females with a family history of breast cancer - While family history is a risk factor, the recommendation for annual clinical breast examinations typically begins at age 40, regardless of family history.
Question 9 of 9
A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B: Educational programs that focus on control and prevention. This intervention is the most crucial as it directly addresses the issue of the increasing incidence of HIV infection. By providing education on how to control and prevent the spread of HIV, the nurse can empower the community to take proactive measures to reduce transmission rates. A: Lifestyle actions that improve immune function may be helpful in general health promotion but do not directly target the prevention of HIV transmission. C: Appropriate use of standard precautions is important but is more focused on healthcare settings rather than community-wide prevention efforts. D: Screening programs for youth and young adults are valuable but may not be as effective as educational programs in preventing the spread of HIV.