ATI RN
test bank foundations of nursing Questions
Question 1 of 9
Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication?
Correct Answer: C
Rationale: The correct answer is C: Normal deep tendon reflexes. This indicates a therapeutic level of magnesium sulfate as it shows that the medication is effectively preventing hyperreflexia, a common sign of magnesium toxicity. Drowsiness (choice A) can indicate toxicity. Urinary output of 20 mL/hour (choice B) is not specific to magnesium sulfate levels. Respiratory rate of 10 to 12 breaths per minute (choice D) is indicative of respiratory depression, a sign of magnesium toxicity. Thus, choice C is the best assessment to indicate a therapeutic level of medication in a patient with preeclampsia taking magnesium sulfate.
Question 2 of 9
An adolescent patients history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this patient consequently faces an increased risk of what health problem?
Correct Answer: D
Rationale: The correct answer is D: Asthma. Atopic dermatitis is associated with a heightened immune response and inflammation, which can predispose individuals to developing asthma. Both conditions involve an overactive immune response and can coexist in patients due to shared genetic and environmental factors. Asthma commonly presents alongside atopic dermatitis in individuals with atopic tendencies. Bronchitis (choice A) is a respiratory condition caused by inflammation of the bronchial tubes and is not directly linked to atopic dermatitis. Systemic lupus erythematosus (choice B) and rheumatoid arthritis (choice C) are autoimmune diseases that primarily affect the joints and other organs, but they are not typically associated with atopic dermatitis.
Question 3 of 9
A nurse is describing the purposes of a healthcare record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all thatapply.)
Correct Answer: A
Rationale: The correct answer is A: Communication. Healthcare records are essential for effective communication among healthcare providers to ensure continuity of care. They help convey important information about a patient's condition, treatment plan, and progress. Explanation: 1. Communication: Healthcare records facilitate communication between different healthcare team members, ensuring coordinated and efficient care delivery. 2. Legal documentation: While important, legal documentation is a separate purpose of healthcare records, not directly related to communication. 3. Reimbursement: Healthcare records are used for billing and reimbursement purposes, but this is not directly related to communication. 4. Nursing process: The nursing process involves assessment, diagnosis, planning, implementation, and evaluation of patient care, which is documented in healthcare records. However, this is not a primary purpose related to communication.
Question 4 of 9
A nurse is taking a history on a patient whocannot speak English. Which action will the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Obtain an interpreter. This is the best action as it ensures effective communication and accurate understanding of the patient's history and needs. Using a professional interpreter maintains confidentiality, avoids misinterpretation, and promotes cultural sensitivity. Referring to a speech therapist (B) is not appropriate for language barriers. Letting a family member talk (C) may compromise privacy and accuracy. Finding a mental health nurse specialist (D) is not needed for language translation.
Question 5 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 6 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 7 of 9
A nurse is using the explanatory model to determinethe etiology of an illness. Which questions should the nurse ask? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: What do you call your problem? In the explanatory model, this question helps the nurse understand the patient's perspective and cultural beliefs about their illness. By asking how the patient labels their illness, the nurse gains insight into the patient's understanding of the illness, which can influence their treatment adherence and outcomes. The other options are incorrect because: A: How should your sickness be treated? - This question focuses on treatment preferences rather than understanding the patient's beliefs. C: How does this illness work inside your body? - This question is more aligned with the biomedical model, seeking physiological explanations rather than patient perspectives. D: What do you fear most about your sickness? - While important for assessing emotional aspects, this question does not directly address the patient's explanatory model.
Question 8 of 9
The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?
Correct Answer: C
Rationale: The correct term for the involuntary, rhythmic eye movements seen in the patient with multiple sclerosis is nystagmus. Nystagmus is a condition characterized by repetitive, uncontrolled eye movements that can be horizontal, vertical, or rotary. In multiple sclerosis, nystagmus can occur due to damage to the nerves that control eye movement. Vertigo (choice A) is a sensation of spinning or dizziness, not related to eye movements. Tinnitus (choice B) is a perception of noise or ringing in the ears. Astigmatism (choice D) is a refractive error of the eye, not related to involuntary eye movements.
Question 9 of 9
A pediatric nurse is emotionally distraught by the death of a 9-year-old girl who received care on the unit over the course of many admissions spanning several years. What action is the most appropriate response to the nurses own grief?
Correct Answer: A
Rationale: The correct answer is A because taking time off from work to mourn allows the nurse to process their emotions and prevent burnout. This self-care step promotes mental well-being and helps prevent the nurse from being overwhelmed by their grief. Choice B is incorrect as it may prolong the grieving process and create a constant reminder of the loss. Choice C could potentially burden the patient's family with the nurse's grief, making it an inappropriate action. Choice D, attending the memorial service, may be emotionally challenging and may not provide the nurse with the necessary space to cope with their grief effectively.