ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patients health history is most likely to be linked to the patients hearing deficit?
Correct Answer: D
Rationale: The correct answer is D: Previous perforation of the eardrum. A perforated eardrum can lead to hearing loss as it affects the transmission of sound waves to the inner ear. This is the most likely link to the patient's hearing deficit as trauma or injury to the eardrum can directly impact hearing. Incorrect choices: A: Recent completion of radiation therapy for treatment of thyroid cancer - Radiation therapy for thyroid cancer typically does not directly affect hearing. B: Routine use of quinine for management of leg cramps - Quinine use is associated with tinnitus (ringing in the ears) but not typically with hearing loss. C: Allergy to hair coloring and hair spray - Allergy to hair products is not directly related to hearing loss. In summary, the most likely cause of the patient's hearing deficit based on the health history provided is the previous perforation of the eardrum, as it directly affects the transmission of sound waves to the inner ear.
Question 2 of 9
The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?
Correct Answer: A
Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely
Question 3 of 9
A nurse is providing care to a patient with anindwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)?
Correct Answer: A
Rationale: The correct answer is A: Drapes the urinary drainage tubing with no dependent loops. This practice helps prevent CAUTI by ensuring that urine does not flow back into the bladder, reducing the risk of infection. Dependent loops can lead to stagnant urine, providing a breeding ground for bacteria. Choice B is incorrect because washing the drainage tube towards the meatus can introduce bacteria into the urinary tract, increasing the risk of infection. Choice C is incorrect because placing the drainage bag on the floor can introduce contaminants from the floor into the system. Choice D is incorrect because allowing the spigot to touch the receptacle can lead to contamination and increase the risk of infection.
Question 4 of 9
A patient is to undergo an ultrasound-guided core biopsy. The patient tells the nurse that a friend of hers had a stereotactic core biopsy. She wants to understand the differences between the two procedures.What would be the nurses best response?
Correct Answer: A
Rationale: The correct answer is A because an ultrasound-guided core biopsy is indeed faster, less expensive, and does not use radiation. - "Faster": Ultrasound-guided biopsies are typically quicker compared to stereotactic biopsies, as they are performed in real-time using ultrasound imaging. - "Less expensive": Ultrasound-guided biopsies are generally more cost-effective than stereotactic biopsies due to the equipment and resources required. - "Does not use radiation": Unlike stereotactic biopsies which involve the use of X-rays for guidance, ultrasound-guided biopsies do not expose the patient to radiation, making them safer in that aspect. The other choices are incorrect because they either inaccurately state that ultrasound-guided biopsies use radiation (C), take more time (D), or imply a slight increase in cost without highlighting the key advantages of speed and lack of radiation (B).
Question 5 of 9
The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction?
Correct Answer: A
Rationale: The correct answer is A: Anaphylactic reaction after a bee sting. Type I hypersensitivity reactions involve an immediate response triggered by exposure to an allergen, leading to the release of histamine and other inflammatory mediators. In this case, a bee sting would introduce an allergen, causing a rapid and severe systemic reaction, known as anaphylaxis. B: Skin reaction resulting from adhesive tape is an example of a Type IV hypersensitivity reaction, mediated by T cells, not IgE antibodies as in Type I reactions. C: Myasthenia gravis is an autoimmune disorder involving antibodies attacking acetylcholine receptors, not a Type I hypersensitivity reaction. D: Rheumatoid arthritis is an autoimmune disorder involving immune complexes and inflammatory responses, not a Type I hypersensitivity reaction.
Question 6 of 9
A patient who has had a lumpectomy calls the clinic to talk to the nurse. The patient tells the nurse that she has developed a tender area on her breast that is red and warm and looks like someone drew a line with a red marker. What would the nurse suspect is the womans problem?
Correct Answer: A
Rationale: The correct answer is A: Mondor disease. This condition presents as a superficial thrombophlebitis of the breast veins, causing a tender, red, warm, cord-like area resembling a red line. This is typically benign and self-limiting. B: Deep vein thrombosis (DVT) of the breast is unlikely as it typically involves deeper veins in the extremities. C: Recurrent malignancy is less likely as the symptoms described are more indicative of a benign condition like Mondor disease. D: An area of fat necrosis is also less likely as it usually presents as a painless, firm lump rather than a red, warm, tender area.
Question 7 of 9
A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking?
Correct Answer: A
Rationale: Step 1: The nurse is auditing and monitoring patients' health records, indicating a review process. Step 2: By reviewing patients' health records, the nurse is determining the degree to which standards of care are met. Step 3: This action aligns with auditing, which involves assessing if care meets established standards. Step 4: The other choices are incorrect because they do not directly involve auditing or monitoring for compliance with standards of care. Choice B talks about undocumented care, C about reimbursement, and D about treatment outcomes comparison.
Question 8 of 9
A patient is experiencing oliguria. Which actionshould the nurse performfirst?
Correct Answer: A
Rationale: The correct answer is A: Assess for bladder distention. Oliguria indicates decreased urine output, which could be due to urinary retention. Assessing for bladder distention helps identify the underlying cause. Requesting diuretics (B) without assessing first is premature. Increasing IV fluid rate (C) may worsen the situation if there is urinary retention. Encouraging caffeinated beverages (D) is not appropriate as they can worsen dehydration.
Question 9 of 9
A patient is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this patients care?
Correct Answer: D
Rationale: The correct answer is D: Surgical intervention. Cataracts are a clouding of the lens in the eye, which can lead to vision impairment. Surgery is the most common and effective treatment for cataracts, involving the removal of the cloudy lens and replacement with an artificial one. Antioxidant supplements (Choice A) may help prevent cataracts but are not a treatment for existing ones. Eyeglasses or magnifying lenses (Choice B) can help with vision correction but do not address the cataracts themselves. Corticosteroid eye drops (Choice C) are used for treating inflammation in the eye, not cataracts. Therefore, surgical intervention is the most appropriate treatment option for age-related cataracts.