ATI RN
foundation of nursing questions Questions
Question 1 of 9
When planning discharge teaching with a patient who has undergone a total mastectomy with axillary dissection, the nurse knows to instruct the patient that she should report what sign or symptom to the physician immediately?
Correct Answer: C
Rationale: The correct answer is C: Sudden cessation of output from the drainage device. This is crucial because it can indicate a potential complication like a blocked drain or infection, requiring immediate medical attention to prevent further issues. Other choices like fatigue (A) are common after surgery but not urgent. Temperature elevation (B) may indicate infection but is not as critical as sudden cessation of drainage. Gradual decline in output (D) is expected as the drainage decreases over time, so it doesn't require immediate reporting.
Question 2 of 9
A clinic nurse is providing preprocedure education for a man who will undergo a vasectomy. Which of the following measures will enhance healing and comfort? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Abstaining from sexual intercourse for at least 14 days postprocedure. This is important to allow the surgical site to heal properly and reduce the risk of complications. Choice B, wearing a scrotal support garment, can provide comfort but does not directly enhance healing. Choice C, using sitz baths, may help with discomfort but may not specifically promote healing. Choice D, applying a heating pad intermittently, could potentially increase the risk of infection. Choice E, staying on bed rest for 48 to 72 hours postprocedure, is unnecessary and could lead to complications such as blood clots.
Question 3 of 9
A 67-year-old woman experienced the death of her husband from a sudden myocardial infarction 5 weeks ago. The nurse recognizes that the woman will be going through the process of mourning for an extended period of time. What processes of mourning will allow the woman to accommodate the loss in a healthy way? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: Reinvesting in new relationships at the appropriate time. This process of mourning involves the woman gradually shifting her focus from the past relationship with her husband to forming new relationships or reinvesting in existing ones. This is crucial for her to adapt to life without her husband and move forward in a healthy manner. A: Reiterating her anger at her husband's care team is not a healthy process as it can lead to prolonged resentment and hinder the mourning process. C: Reminiscing about the relationship she had with her husband is a natural part of mourning but solely focusing on reminiscing may not allow her to fully adapt to life without her husband. D: Relinquishing old attachments to her husband at the appropriate time is important, but it is only one aspect of the mourning process. It is not the sole process necessary for healthy mourning. E: Renewing her lifelong commitment to her husband is not a healthy process as it prevents her from accepting the loss and
Question 4 of 9
A nurse is completing an OASIS data set on apatient. The nurse works in which area?
Correct Answer: A
Rationale: The correct answer is A: Home health. The Outcome and Assessment Information Set (OASIS) data set is specifically used in the home health care setting to assess the patient's condition and needs. This includes collecting data on the patient's health, functional status, and living environment to determine the appropriate care plan. In contrast, choices B, C, and D are incorrect because OASIS is not utilized in the intensive care unit, skilled nursing facility, or long-term care facility settings. These settings have their own assessment tools and documentation requirements that are different from OASIS used in home health care.
Question 5 of 9
When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?
Correct Answer: C
Rationale: The correct answer is C: Invasion of the uterine wall by endometrial tissue. Adenomyosis is a condition where endometrial tissue grows into the muscular wall of the uterus, causing symptoms like heavy menstrual bleeding and severe cramping. This process results in inflammation, thickening of the uterine wall, and can lead to enlargement of the uterus. Choice A: Loss of muscle tone in the vaginal wall is incorrect because adenomyosis does not involve the vaginal wall. Choice B: Excessive synthesis and release of unopposed estrogen is incorrect because although estrogen can contribute to the growth of endometrial tissue, it is not the primary pathophysiologic process in adenomyosis. Choice D: Proliferation of tumors in the uterine wall is incorrect because adenomyosis does not involve the growth of tumors, but rather the infiltration of endometrial tissue into the uterine muscle.
Question 6 of 9
A patient at high risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the patient asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurses best response?
Correct Answer: B
Rationale: The correct answer is B because an incisional biopsy is typically performed to confirm a diagnosis by obtaining a sample of the tissue in question. This allows for further analysis through special studies to determine the best course of treatment. The other choices are incorrect because: A: The reason for performing an incisional biopsy is not primarily based on pain or accuracy comparisons with other testing methods. C: An incisional biopsy is not done to assess potential recovery from a mastectomy but rather to diagnose the nature of the mass. D: Age and general health status are not sole criteria for determining the need for an incisional biopsy.
Question 7 of 9
The nurse is caring for a 39-year-old woman with a family history of breast cancer. She requested a breast tumor marking test and the results have come back positive. As a result, the patient is requesting a bilateral mastectomy. This surgery is an example of what type of oncologic surgery?
Correct Answer: C
Rationale: The correct answer is C: Prophylactic surgery. Prophylactic surgery involves removing tissue at risk of developing cancer to prevent the occurrence of cancer. In this case, the patient has a family history of breast cancer and has tested positive for a breast tumor marker, indicating a high risk of developing breast cancer. By opting for a bilateral mastectomy, the patient is proactively removing breast tissue to reduce her risk of developing breast cancer. Salvage surgery (A) is performed to remove cancer that has recurred after initial treatment. Palliative surgery (B) aims to alleviate symptoms and improve quality of life but is not curative. Reconstructive surgery (D) is performed to restore the appearance and function of a body part after cancer treatment but is not the primary purpose in this scenario.
Question 8 of 9
A patient has been referred to the breast clinic after her most recent mammogram revealed the presence of a lump. The lump is found to be a small, well-defined nodule in the right breast. The oncology nurse should recognize the likelihood of what treatment?
Correct Answer: A
Rationale: The correct answer is A: Lumpectomy and radiation. For a small, well-defined nodule in the breast, lumpectomy (removal of the lump) followed by radiation therapy is usually the treatment of choice for early-stage breast cancer. This approach aims to preserve the breast while ensuring effective treatment. Partial mastectomy (B) involves removing a larger portion of the breast tissue and is not typically necessary for a small, well-defined nodule. Chemotherapy (C) is generally used for more advanced stages of breast cancer or when the cancer has spread beyond the breast. Total mastectomy (D) is considered when the cancer is more extensive or in cases where lumpectomy is not feasible.
Question 9 of 9
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement. Summary of Incorrect Choices: A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach. B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage. D: Measuring from the tip of the nose to the earlobe to