ATI RN
test bank foundations of nursing Questions
Question 1 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 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
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 4 of 9
Spontaneous termination of a pregnancy is considered to be an abortion if
Correct Answer: A
Rationale: The correct answer is A because spontaneous termination of a pregnancy is considered an abortion if it occurs before 20 weeks gestation. This is based on the medical definition of abortion as the termination of a pregnancy before the fetus is able to survive outside the womb. Choices B, C, and D are incorrect as they do not accurately reflect the criteria for defining abortion. B and D are specific conditions related to the fetus and the presence of infection, while C refers to passing products of conception intact, which can happen in both spontaneous and induced abortions.
Question 5 of 9
A patient with Parkinsons disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond?
Correct Answer: C
Rationale: The correct answer is C: Lets explore other options, because laxatives can have side effects and create dependency. The rationale for this is that while laxatives provide temporary relief for constipation, using them long-term can lead to dependency, electrolyte imbalances, and other side effects. The nurse should address the root cause of constipation and explore alternative strategies such as dietary changes, increased fluid intake, exercise, and bowel training. Choices A and B focus on supportive measures rather than addressing the issue of potential dependency on laxatives. Choice D suggests herbal remedies without considering the individual's specific condition and medical history.
Question 6 of 9
A nurse exchanges information with the oncomingnurse about a patient’s care. Which action did the nurse complete?
Correct Answer: A
Rationale: The correct answer is A: A verbal report. This is because exchanging information verbally between nurses allows for real-time communication, ensuring important details are accurately conveyed. Electronic record entry (B) involves documenting information in the patient's record but does not involve direct communication. Referral (C) refers to transferring the patient's care to another healthcare provider. Acuity rating (D) is a tool used to determine the severity of a patient's condition and does not involve exchanging information between nurses.
Question 7 of 9
A nurse is caring for a pregnant patient with active herpes. The teaching plan for this patient should include which of the following?
Correct Answer: A
Rationale: The correct answer is A because babies can become infected with the herpes virus if delivered vaginally. During childbirth, the virus can be passed to the infant, leading to serious health complications. This information is crucial for the patient to understand in order to make informed decisions about delivery options. Choice B is incorrect because excision of herpes lesions is not the recommended treatment during pregnancy. Treatment typically involves antiviral medications to manage symptoms and reduce the risk of transmission to the baby. Choice C is incorrect because herpes outbreaks can indeed be painful during pregnancy due to hormonal changes and a weakened immune system. Pain management strategies should be discussed as part of the teaching plan. Choice D is incorrect because pregnancy can pose a risk to the infant if the mother has active herpes. It is important to manage the condition appropriately to prevent transmission to the baby.
Question 8 of 9
The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patients immediate family members to undergo clinical examinations how often?
Correct Answer: B
Rationale: The correct answer is B: At least once every 2 years. Glaucoma has a familial tendency, meaning it can run in families. Regular eye exams are crucial for early detection and treatment. Having family members undergo clinical examinations every 2 years allows for timely identification of any potential signs of glaucoma. Monthly exams (A) would be too frequent and unnecessary. Exams every 5 years (C) or 10 years (D) are too infrequent and may miss early signs of the disease. Regular biennial exams strike a balance between early detection and practicality.
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.