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 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 3 of 9
The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively?
Correct Answer: B
Rationale: The correct answer is B. By asking the patient to demonstrate the instillation of medications, the nurse can directly assess the patient's ability to self-administer the medications safely and effectively. This method allows for a practical demonstration of skills, which is more reliable than relying solely on verbal descriptions or past experiences. Choices A, C, and D are incorrect because assessing for previous inability, describing the method, or evaluating functional status may not directly demonstrate the patient's competency in self-administering ocular medications.
Question 4 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 5 of 9
After mastoid surgery, an 81-year-old patient has been identified as needing assistance in her home. What would be a primary focus of this patients home care?
Correct Answer: A
Rationale: The correct answer is A: Preparation of nutritious meals and avoidance of contraindicated foods. After mastoid surgery, proper nutrition is crucial for healing and recovery. Nutritious meals support the immune system and aid in tissue repair. Avoiding contraindicated foods, such as those that may cause inflammation or interfere with medications, is essential for the patient's well-being. Choices B, C, and D are not the primary focus of home care after mastoid surgery. While rest, adaptation to hearing loss, and assistance with ambulation are important, they are secondary to ensuring proper nutrition for optimal recovery in this case.
Question 6 of 9
Which form of heart disease in women of childbearing years usually has a benign effect on pregnancy?
Correct Answer: B
Rationale: The correct answer is B: Mitral valve prolapse. This condition is usually benign during pregnancy because the heart's workload increases, and the mitral valve is a one-way valve that prevents blood from flowing back into the left atrium. Mitral valve prolapse typically does not significantly affect the heart's ability to pump blood efficiently during pregnancy. Rationale: 1. Cardiomyopathy (A) can worsen during pregnancy, leading to complications for both the mother and the fetus. 2. Rheumatic heart disease (C) can cause valve damage, increasing the risk of complications during pregnancy. 3. Congenital heart disease (D) varies in severity and can pose risks during pregnancy, depending on the specific condition. Summary: Mitral valve prolapse is the correct answer as it is less likely to cause significant issues during pregnancy compared to the other options provided.
Question 7 of 9
A gerontologic nurse is advocating for diagnostic testing of an 81-year-old patient who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults?
Correct Answer: A
Rationale: The correct answer is A because the cognitive effects of aging can mimic symptoms of brain tumors in older adults, leading to misdiagnosis or delayed diagnosis. Aging can also affect the presentation, progression, and treatment outcomes of brain tumors. Option B is incorrect as brain tumors in older adults can indeed produce focal effects. Option C is incorrect as not all older adults have numerous benign brain tumors, and this is not a factor affecting the diagnosis and treatment of brain tumors in this case. Option D is incorrect as age alone does not preclude treatment for brain tumors.
Question 8 of 9
A nurse practitioner is examining a patient who presented at the free clinic with vulvar pruritus. For which assessment finding would the practitioner look that may indicate the patient has an infection caused by Candida albicans?
Correct Answer: A
Rationale: The correct answer is A: Cottage cheese-like discharge. Candida albicans is a common cause of vulvovaginal candidiasis, characterized by itching and cottage cheese-like discharge. This type of discharge is specific to a yeast infection. Yellow-green discharge (choice B) is indicative of trichomoniasis, gray-white discharge (choice C) is seen in bacterial vaginosis, and watery discharge with a fishy odor (choice D) is characteristic of bacterial vaginosis or trichomoniasis. Therefore, the presence of cottage cheese-like discharge is a key indicator of a Candida albicans infection.
Question 9 of 9
A patient has been prescribed sildenafil. What should the nurse teach the patient about this medication?
Correct Answer: A
Rationale: The correct answer is A because sildenafil works by enhancing the effects of nitric oxide, which is released during sexual stimulation to relax the muscles in the penis and increase blood flow for an erection. Therefore, sexual stimulation is necessary for the medication to be effective. Explanation of other choices: B: While sildenafil is typically taken 30 minutes to 4 hours before sexual activity, it does not need to be exactly 1 hour prior. C: Facial flushing and headache are common side effects of sildenafil but do not require immediate reporting unless severe or persistent. D: Sildenafil may cause temporary visual disturbances like changes in color vision, but permanent visual changes are rare.