ATI RN
test bank foundations of nursing Questions
Question 1 of 9
The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient’s skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?
Correct Answer: A
Rationale: The correct answer is A: Drink more water to prevent further dehydration. Given the patient's fair skin turgor, fatigue, weakness, warm and dry skin, elevated pulse rate, and slightly elevated urinary sodium level, these are signs of dehydration. Increasing water intake would help improve the patient's hydration status. Other choices are incorrect because B (calorie-dense fluids) does not address the dehydration issue, C (milk and dairy products) does not directly address the symptoms presented, and D (grapefruit juice) is not essential for hydration in this case.
Question 2 of 9
A medical nurse is providing palliative care to a patient with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurses care?
Correct Answer: A
Rationale: The correct answer is A: To improve the patients and familys quality of life. In palliative care for end-stage COPD, the primary goal is to enhance quality of life by managing symptoms, providing emotional support, and ensuring comfort. Choice B is incorrect as palliative care focuses on comfort rather than aggressive treatments. Choice C is incorrect because palliative care encompasses not only physical but also emotional, social, and spiritual support. Choice D is incorrect as the goal is to provide holistic care rather than separate plans for each discipline. Ultimately, the primary focus of palliative care in this scenario is to improve the overall quality of life for the patient and their family.
Question 3 of 9
An oncology nurse educator is providing health education to a patient who has been diagnosed with skin cancer. The patients wife has asked about the differences between normal cells and cancer cells. What characteristic of a cancer cell should the educator cite?
Correct Answer: B
Rationale: The correct answer is B: Malignant cells contain proteins called tumor-specific antigens. Tumor-specific antigens are unique to cancer cells and are not found in normal cells. This characteristic distinguishes cancer cells from normal cells and is important in cancer detection and treatment. A: Malignant cells do not necessarily contain more fibronectin than normal body cells. Fibronectin is a glycoprotein found in the extracellular matrix and is not a defining characteristic of cancer cells. C: Chromosomes in cancer cells are actually more prone to instability and mutations compared to normal cells, making them less durable and stable. D: The nuclei of cancer cells can vary in size and shape, with irregularities often seen, rather than being unusually large and regularly shaped.
Question 4 of 9
A nurse is preparing a patient for a magneticresonance imaging (MRI) scan. Which nursing action ismostimportant?
Correct Answer: D
Rationale: Correct Answer: D - Removing all of the patient’s metallic jewelry. Rationale: 1. Safety: Metallic objects can be attracted by the MRI magnet, causing harm to the patient and disrupting the imaging process. 2. Artifact Prevention: Metallic objects can produce artifacts on the MRI images, affecting the diagnostic quality. 3. Patient Comfort: Removing jewelry ensures the patient's comfort during the scan, avoiding discomfort or injury. Summary of Incorrect Choices: A: Not eating or drinking before an MRI is important, but it is not the most crucial action compared to patient safety and image quality. B: Colon cleansing may be necessary for certain types of MRI scans, but it is not universally required and is not the most important action. C: Pain medication may be important for patient comfort, but it is not essential for the actual MRI procedure and does not impact safety or image quality.
Question 5 of 9
A patient has just been diagnosed with Parkinsons disease and the nurse is planning the patients subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patients family?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. Patients with Parkinson's disease are at risk for falls due to symptoms like tremors and impaired balance. Educating the family about fall prevention measures is crucial. Choice A, Risk for infection, is not directly related to Parkinson's disease. Choice B, Impaired spontaneous ventilation, is not a common concern in Parkinson's disease. Choice C, Unilateral neglect, is more commonly seen in conditions like stroke, not Parkinson's disease. Therefore, the most appropriate nursing diagnosis for the patient with Parkinson's disease is addressing the risk for injury to prevent falls.
Question 6 of 9
A patient newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the patient to implement?
Correct Answer: B
Rationale: The correct answer is B: Sleep on a firm mattress. A firm mattress helps maintain proper spinal alignment, reducing pressure on the cervical spine. This promotes healing and prevents worsening of symptoms. A: Performing active ROM exercises may exacerbate symptoms and worsen the condition. C: Applying cool compresses may provide temporary relief but does not address the underlying issue of spinal alignment. D: Wearing a cervical collar for extended periods can weaken neck muscles and hinder natural healing processes. In summary, sleeping on a firm mattress is the most appropriate conservative measure as it supports proper spinal alignment.
Question 7 of 9
A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child?
Correct Answer: A
Rationale: Step 1: Handwashing is crucial in preventing the spread of viral conjunctivitis, which is highly contagious. Step 2: Children often touch their eyes and then surfaces, aiding in disease transmission. Step 3: Educating parents and the child on proper hand hygiene can help contain the infection. Step 4: Antibiotics are not effective against viral infections, so compliance is not necessary. Step 5: Complications like meningitis and septicemia are extremely rare with viral conjunctivitis. Step 6: Surgery is not indicated for viral conjunctivitis, as it is a self-limiting condition.
Question 8 of 9
The nurse is caring for a patient who has just had a radical mastectomy and axillary node dissection. When providing patient education regarding rehabilitation, what should the nurse recommend?
Correct Answer: C
Rationale: The correct answer is C: Avoid lifting objects heavier than 10 pounds. This recommendation is crucial post-mastectomy as it helps prevent lymphedema and promotes healing without causing strain on the surgical site. Lifting heavy objects can lead to complications such as lymphedema or disruption of the healing process. Options A, B, and D are incorrect as avoiding exercise of the arm for 2 months may lead to stiffness and reduced range of motion, keeping cuticles clipped neatly does not directly affect rehabilitation, and using a sling is not necessary unless specifically advised by the healthcare provider.
Question 9 of 9
A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy?
Correct Answer: D
Rationale: The correct answer is D because patients with lower health literacy, such as those with a high-school diploma, may struggle to understand complex health information. The nurse should assess this patient closely to ensure they comprehend and can follow instructions. Patients with higher education levels (college degree) may have better health literacy skills. Age alone (35 or 68 years old) does not determine health literacy level. It is essential to focus on the patient's educational background to assess their health literacy effectively.