ATI RN
Foundations and Adult Health Nursing Test Bank Questions
Question 1 of 9
To ensure quality nursing care to a patient in skin traction, what is the PRIORTTY intervention that a nurse has to assess frequently?
Correct Answer: B
Rationale: When a patient is in skin traction, the constant pressure and rubbing against the skin from the traction device can lead to skin breakdown. Therefore, assessing for signs of skin breakdown, such as redness, irritation, or pressure injuries, is crucial to prevent complications and ensure the patient's comfort and safety. Prompt identification and intervention for any skin issues can prevent further damage and promote healing, making this the priority intervention for quality nursing care in skin traction. While monitoring for signs of infection, urinary incontinence, and bowel sounds are important, skin breakdown poses a more immediate threat to the patient's well-being in this scenario.
Question 2 of 9
A nurse is preparing to assist with a transesophageal echocardiogram (TEE) procedure for a patient. What action should the nurse prioritize to ensure patient safety during TEE?
Correct Answer: D
Rationale: Ensuring the availability of emergency equipment and resuscitation medications is crucial to prioritize patient safety during a transesophageal echocardiogram (TEE) procedure. TEE involves inserting a specialized probe (transducer) into the esophagus to obtain detailed images of the heart. While complications during TEE are rare, they can include adverse reactions to sedation, esophageal injury, arrhythmias, or other cardiac events. By having emergency equipment and resuscitation medications readily available, the healthcare team can respond promptly to any unforeseen complications or emergencies that may arise during the procedure, ensuring optimal patient safety. Placing the patient in a supine position, providing sedation, and advising the patient to fast before the procedure are important aspects of the TEE process; however, ensuring emergency preparedness takes precedence in prioritizing patient safety during the procedure.
Question 3 of 9
A patient with systemic lupus erythematosus (SLE) demonstrates a positive antinuclear antibody (ANA) test and elevated levels of anti-double-stranded DNA (anti-dsDNA) antibodies. Which of the following mechanisms is most likely responsible for the production of these autoantibodies?
Correct Answer: A
Rationale: The development of autoantibodies such as antinuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies in systemic lupus erythematosus (SLE) is primarily attributed to a loss of self-tolerance. Self-tolerance refers to the immune system's ability to recognize and differentiate self-antigens from foreign antigens. In individuals with SLE, there is a breakdown in immune tolerance mechanisms, leading to the production of autoantibodies against self-antigens like nuclear components (e.g., DNA, RNA, histones). This loss of self-tolerance results in the immune system targeting and attacking its tissues, leading to the systemic inflammation and tissue damage characteristic of SLE. The presence of elevated levels of ANA and anti-dsDNA antibodies in this patient suggests an autoimmune response against nuclear material, further supporting the role of self-tolerance breakdown in SLE
Question 4 of 9
Doing year end performance evaluation of the staff is an example of
Correct Answer: C
Rationale: Conducting a year-end performance evaluation of the staff is an example of a controlling function in management. Controlling involves monitoring and evaluating the performance of employees to ensure that they are working effectively and meeting the set goals and standards. By assessing the staff's performance at the end of the year, managers can identify areas of improvement, provide feedback, and make necessary adjustments to ensure the overall success of the organization. Hence, the process of evaluating staff performance falls under the controlling function of management.
Question 5 of 9
The PRC-Board of Nursing (PR-BON) has the power to regulate Nursing Practice in the Philippines. The regulatory functions include the following except
Correct Answer: D
Rationale: The Philippine Regulatory Commission - Board of Nursing (PRC-BON) has the power to regulate nursing practice in the Philippines.
Question 6 of 9
A patient is reluctant to undergo a recommended procedure due to fear of pain. What is the nurse's best approach to address this fear?
Correct Answer: B
Rationale: The nurse's best approach to address the patient's fear of pain is to provide accurate information about pain management strategies and options. In doing so, the nurse can help alleviate the patient's concerns by empowering them with knowledge and potential solutions for managing pain during and after the procedure. By acknowledging the patient's fear and addressing it with practical information, the nurse can build trust, reduce anxiety, and create a more supportive and collaborative environment for the patient. Dismissing, ignoring, or invalidating the patient's fear would not be effective in addressing the underlying concerns and could potentially lead to increased distress and resistance to the recommended procedure.
Question 7 of 9
Romy is diagnosed with small cell lung cancer (SCLC) a rapidly growing type of cancer. He and his family were shocked when told by the doctor that the patient will just undergo palliative treatment. Which nursing action is MOST APPROPRIATE?
Correct Answer: A
Rationale: In the case of Romy being diagnosed with small cell lung cancer (SCLC) and undergoing palliative treatment, the most appropriate nursing action is to focus on providing relief from symptoms. Palliative care aims to improve the quality of life for patients with serious illnesses by managing their symptoms, such as pain, shortness of breath, nausea, and other side effects of treatment. As the cancer is advanced and the goal is not curative treatment but rather to keep the patient comfortable, symptom management becomes a priority to ensure Romy's physical comfort and well-being during this difficult time. Providing relief from symptoms is crucial in palliative care to help enhance the patient's quality of life and ensure they are as comfortable as possible.
Question 8 of 9
The blood protein involved in the immune system is:
Correct Answer: C
Rationale: Globulin is the blood protein involved in the immune system. There are different types of globulins, including immunoglobulins (antibodies) that play a crucial role in the body's defense against infections. These antibodies bind to foreign substances, such as bacteria and viruses, helping the immune system to recognize and destroy them. Thrombin is a clotting protein, albumin is a protein responsible for maintaining osmotic balance in the blood, and hemoglobin is a protein found in red blood cells that carries oxygen.
Question 9 of 9
During a home visit, a member of the family you're visiting who has been using marijuana for three years tells theyou that he wants to be 'detoxified'. It is important for the nurse to ____.
Correct Answer: B
Rationale: Identifying the patient's stage of change is crucial when someone expresses a desire to be "detoxified" from a substance like marijuana. The Transtheoretical Model (Stages of Change) outlines different stages individuals go through when making behavior changes. By identifying which stage the patient is in (precontemplation, contemplation, preparation, action, maintenance, or relapse), the nurse can tailor interventions and support accordingly. This approach helps ensure that interventions are effective and appropriate for the individual's readiness for change. It is important to meet the patient where they are in their journey towards detoxification and offer support and guidance accordingly.