ATI RN
foundations of nursing practice questions Questions
Question 1 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 2 of 9
A nurse is watching a nursing assistive personnel(NAP) perform a postvoid bladder scan on a female with a previous hysterectomy. Which action will require the nurse to follow up?
Correct Answer: D
Rationale: The correct answer is D because setting the scanner to female is incorrect for a patient who has had a hysterectomy as they do not have a uterus. This could lead to inaccurate results. Palpating the symphysis pubis (A) ensures proper positioning, wiping the scanner head with alcohol (B) maintains infection control, and applying gel (C) facilitates sound wave transmission.
Question 3 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 4 of 9
The nurse is caring for a patient with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patients plan of care?
Correct Answer: C
Rationale: The correct answer is C: Encourage the patient to keep his or her feeding area clean. This is the most appropriate independent nursing action as it promotes hygiene and reduces the risk of infection. Keeping the feeding area clean is essential in preventing complications in a patient with malnutrition. Rationales for why the other choices are incorrect: A: Firmly redirect the patient's head when feeding - This is incorrect because forceful redirection can cause distress and discomfort to the patient, potentially leading to aspiration or choking. B: Administer phenothiazines after each meal as ordered - This is incorrect as phenothiazines are not typically used for malnutrition treatment and should not be administered without a specific indication. D: Apply deep, gentle pressure around the patient's mouth to aid swallowing - This is incorrect because applying pressure around the mouth can pose a choking hazard and should not be done without proper assessment and intervention by a speech therapist or swallowing specialist.
Question 5 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.
Question 6 of 9
A patient is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the patients statements best demonstrates an adequate understanding?
Correct Answer: D
Rationale: The correct answer is D: "I need to call the doctor if I see flashing lights." This is because seeing flashing lights after cataract extraction with intraocular lens implant can be a sign of a serious complication like retinal detachment. Prompt reporting is crucial to prevent vision loss. Choice A is incorrect because nausea is not typically a sign of a complication related to cataract surgery. Choice B is also incorrect as a light morning discharge is normal post-surgery unless it's excessive or associated with pain or visual changes. Choice C is incorrect as a scratchy feeling is common after surgery and usually resolves on its own.
Question 7 of 9
A patient who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The labor and birth nurse performs the NfollRowiIng aGssesBsm.eCntsM. The vaginal exam is deferred until the U S N T O physician is in attendance. The patient is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The patient is then transferred to the antepartum unit for continued observation. Several hours later, the patient complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The patient is placed on the EFM and no fetal heart tones are observed. What does the nurse suspect is occurring?
Correct Answer: D
Rationale: The correct answer is D: Hidden placental abruption. In this scenario, the patient had PROM and is now presenting with decreased fetal movement and absence of fetal heart tones after a fundal height increase. These signs suggest a hidden placental abruption, where the placenta has partially detached, leading to fetal distress and potential fetal demise. The absence of contractions rules out active labor (B) as the cause. Placental previa (A) would typically present with painless vaginal bleeding, which is not described in the scenario. Placental abruption (C) usually presents with painful vaginal bleeding, which is also not mentioned. Therefore, the most likely explanation for the symptoms described is a hidden placental abruption.
Question 8 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 9 of 9
The nurse is developing a plan of care for a patient newly diagnosed with Bells palsy. The nurses plan of care should address what characteristic manifestation of this disease?
Correct Answer: B
Rationale: The correct answer is B: Facial paralysis. Bell's palsy is characterized by sudden, temporary weakness or paralysis of the facial muscles on one side of the face. This manifests as drooping of the eyelid and corner of the mouth, difficulty smiling or closing the eye. Tinnitus (A) is ringing in the ears, not a common symptom of Bell's palsy. Pain at the base of the tongue (C) is not a typical manifestation of Bell's palsy. Diplopia (D) is double vision, which is not a primary symptom of Bell's palsy. Therefore, the correct manifestation to address in the plan of care for a patient with Bell's palsy is facial paralysis.