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
A nurse is caring for a patient who just underwentan intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse’sfirstpriorityin caring for this patient?
Correct Answer: C
Rationale: The correct answer is C: Monitor the patient for fever, rash, and difficulty breathing. The rationale is as follows: 1. Renal calculus obstruction can lead to complications such as infection, so monitoring for fever is crucial. 2. Rash can indicate an allergic reaction to the contrast dye used in the procedure. 3. Difficulty breathing may signal a severe reaction or complications. Summary: A: Turning the patient on the right side does not directly address the urgent need to monitor for potential complications. B: While fluid intake is important, it is not the immediate priority when the patient is at risk of developing complications. D: Administering narcotic medications may be necessary for pain relief but does not address the potential emergent issues related to the obstruction.
Question 3 of 9
A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority?
Correct Answer: C
Rationale: The correct answer is C: Promote positive nitrogen balance. In a postsurgical patient, promoting positive nitrogen balance is crucial for wound healing and tissue repair. This goal helps prevent muscle wasting and promotes overall recovery. A: Reduce dependent nitrogen balance is incorrect as it does not address the need for positive nitrogen balance in wound healing. B: Maintain negative nitrogen balance is incorrect because negative nitrogen balance indicates a loss of protein stores, which is detrimental for healing. D: Facilitate neutral nitrogen balance is incorrect as it does not actively support the increased protein needs for wound repair.
Question 4 of 9
During a recent visit to the clinic a woman presents with erythema of the nipple and areola on the right breast. She states this started several weeks ago and she was fearful of what would be found. The nurse should promptly refer the patient to her primary care provider because the patients signs and symptoms are suggestive of what health problem?
Correct Answer: C
Rationale: Rationale: 1. Erythema of nipple/areola in one breast can be a sign of Paget's disease, a rare form of breast cancer. 2. Paget's disease may also present with itching, tingling, or a burning sensation in the affected area. 3. Referring the patient promptly is crucial for early detection and appropriate management. 4. Peau d'orange (A) is a sign of advanced breast cancer, not typically presenting with erythema alone. 5. Nipple inversion (B) may be benign or related to other conditions, not typically presenting with erythema. 6. Acute mastitis (D) presents with breast pain, warmth, swelling, and fever, but not typically with isolated erythema of the nipple/areola.
Question 5 of 9
As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that
Correct Answer: A
Rationale: The correct answer is A: immediate birth is required. The Kleihauer–Betke test is used to detect fetal-maternal hemorrhage in situations where there is a risk of fetal blood entering the maternal circulation, such as trauma during pregnancy. A positive result indicates a significant fetal-maternal hemorrhage, which can lead to Rh incompatibility and severe fetal anemia. Immediate birth is required to prevent complications and ensure the safety of both the mother and the baby. Choice B is incorrect as transferring the patient to the critical care unit does not address the underlying issue of fetal-maternal hemorrhage. Choice C is incorrect as RhoGAM is typically administered to prevent Rh sensitization in Rh-negative mothers carrying Rh-positive babies, which is not the primary concern in this scenario. Choice D is incorrect as a tetanus shot is not directly related to the positive Kleihauer–Betke test result indicating fetal-maternal hemorrhage.
Question 6 of 9
A patient was prescribed an oral antibiotic for the treatment of sinusitis. The patient has now stopped, stating she developed a rash shortly after taking the first dose of the drug. What is the nurses most appropriate response?
Correct Answer: B
Rationale: The correct answer is B: Refer the woman to her primary care provider to have the medication changed. Rationale: 1. Rash after taking the first dose of an antibiotic suggests a possible allergic reaction. 2. Allergic reactions can range from mild to severe, including anaphylaxis. 3. It is crucial to discontinue the suspected medication to prevent worsening of the reaction. 4. Referring the patient to their primary care provider ensures proper evaluation and management. 5. Changing the medication is necessary to avoid potential harm from continued exposure. Summary: A: Continuing the medication can worsen the allergic reaction and is not recommended. C: Going to the emergency department may be excessive at this point for a mild rash. D: Taking an antihistamine does not address the underlying issue of an allergic reaction.
Question 7 of 9
When teaching patients about the risk factors of cervical cancer, what would the nurse identify as the most important risk factor?
Correct Answer: B
Rationale: The correct answer is B: Human papillomavirus (HPV). HPV is the most important risk factor for cervical cancer as it is responsible for almost all cases. Step 1: HPV infection can lead to changes in cervical cells, increasing the risk of cancer. Step 2: Early detection and vaccination against HPV can prevent cervical cancer. Step 3: Other factors like late childbearing, postmenopausal bleeding, and tobacco use may be associated with increased risk but are not as directly linked to cervical cancer development.
Question 8 of 9
The school nurse is teaching a nutrition class in the local high school. One student states that he has heard that certain foods can increase the incidence of cancer. The nurse responds, Research has shown that certain foods indeed appear to increase the risk of cancer. Which of the following menu selections would be the best choice for potentially reducing the risks of cancer?
Correct Answer: C
Rationale: The correct answer is C: Baked apricot chicken and steamed broccoli. This menu selection is the best choice for potentially reducing the risks of cancer due to several reasons. Baked apricot chicken is a lean protein source without the harmful effects of excessive red or processed meats, which are linked to an increased cancer risk. Apricots are rich in antioxidants like Vitamin C and beta-carotene, which can help protect cells from damage that may lead to cancer. Broccoli is a cruciferous vegetable containing compounds like sulforaphane that have anti-cancer properties. Steaming broccoli helps retain its nutrients better compared to frying or overcooking. Therefore, this menu selection is a balanced, nutritious choice that includes cancer-fighting ingredients and avoids potentially harmful foods like red meats or fried items.
Question 9 of 9
The nurse is caring for a patient of Hispanicdescent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Look at the patient when talking. This is important because maintaining eye contact shows respect, builds trust, and enhances communication with the patient. By looking at the patient, the nurse can also observe nonverbal cues and ensure the patient is engaged in the conversation. Choice A: Using long sentences can be overwhelming for a patient who may not understand the language, leading to miscommunication. Choice C: Using breaks in sentences may help the interpreter better convey the message, but looking at the patient is more essential for effective communication. Choice D: Looking at only nonverbal behaviors neglects the importance of eye contact and direct communication with the patient.