ATI RN
foundation of nursing practice questions Questions
Question 1 of 5
The nurse responds to the call light of a patient who has had a cervical diskectomy earlier in the day. Thecpatient states that she is having severe pain that had a sudden onset. What is the nurses most appropriate action?
Correct Answer: C
Rationale: In this scenario, the patient who has had a cervical diskectomy is experiencing severe pain with a sudden onset, which can be indicative of a complication such as bleeding, infection, or nerve impingement. The nurse's most appropriate action is to call the surgeon immediately to report the patient's pain. The surgeon needs to be informed promptly so that a further assessment can be made and appropriate interventions can be initiated to address the cause of the sudden pain. Palpating the surgical site or removing the dressing without consulting the surgeon first may worsen the situation or increase the risk of complications. Administering an NSAID is not appropriate in this situation without further evaluation and guidance from the surgeon. It is essential to prioritize patient safety and ensure that the patient receives timely and appropriate care by involving the surgeon in the decision-making process.
Question 2 of 5
A patient has a history of drug use and is screened for hepatitis B during the first trimester. Which action is most appropriate?
Correct Answer: B
Rationale: A person who has a history of high-risk behaviors, such as drug use, should be retested for hepatitis B during the third trimester. This is because the virus can have a long incubation period before showing up in blood tests. Retesting in the third trimester ensures that if the infection was acquired after the initial screening, it will be detected in time to provide appropriate care and interventions. Retesting is important in high-risk individuals to ensure proper management and prevention of hepatitis B transmission.
Question 3 of 5
A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene?
Correct Answer: D
Rationale: Mashed potatoes and gravy are not appropriate for a full liquid diet. A full liquid diet consists of foods that are liquid at room temperature or melt into liquid form at body temperature. Mashed potatoes and gravy are not in liquid form and therefore should not be consumed by a patient following a full liquid diet. The nurse should intervene and provide education about the correct food choices allowed on a full liquid diet, such as custard, frozen yogurt, and pureed vegetables.
Question 4 of 5
A female patient with HIV has just been diagnosed with condylomata acuminata (genital warts). What information is most appropriate for the nurse to tell this patient?
Correct Answer: A
Rationale: The most appropriate information for the nurse to tell the patient is option A, which states that this condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually. Condylomata acuminata, or genital warts, is caused by the human papillomavirus (HPV). Certain strains of HPV, specifically types 16 and 18, are considered high-risk strains that can lead to cervical cancer in women. Therefore, regular Pap tests are crucial for early detection of any cervical changes that could indicate pre-cancerous or cancerous lesions. It is important for the patient to be informed about this risk and the importance of regular screening to monitor her cervical health.
Question 5 of 5
The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
Correct Answer: B
Rationale: The signs of magnesium toxicity that the nurse should monitor for in a patient with severe preeclampsia on IV magnesium sulfate include an altered sensorium (confusion, lethargy, slurred speech) and a respiratory rate of less than 12 breaths per minute. Altered sensorium is a common symptom of magnesium toxicity, reflecting the drug's central nervous system depressant effects. A decreased respiratory rate can indicate respiratory depression, a potentially serious complication of magnesium toxicity. Monitoring for these signs is crucial to promptly identifying and managing magnesium toxicity in patients on magnesium sulfate therapy. Signs such as cool, clammy skin and a pulse oximeter reading of 95% would not be indicative of magnesium toxicity.
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