1. ATI RN MATERNAL NEWBORN PROCTORED EXAM
2. The nurse is providing an education session to an adult community group about the effects of smoking
on infection. Which information is most important for the nurse to include in the educational session?
a. Smoke from tobacco products clings to your clothing and hair.
b. Smoking affects the cilia lining the upper airways in the lungs.
c. Smoking can affect the color of the patient’s fingernails.
d. Smoking tobacco products can be very expensive.
ANS: B
A normal defense mechanism against infection in the respiratory tract is the cilia lining the upper airways of
the lungs and normal mucus. When a patient inhales a microbe, the cilia and mucus trap the microbe and
sweep them up and out to be expectorated or swallowed. Smoking may alter this defense mechanism and
increase the patient’s potential for infection. Smoking can be expensive, the smell does cling to hair and
clothing, and the tar within the smoke can alter the color of a patient’s nails. This information can be included
in the education but does not constitute the most important point.
3. A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal
area. A nurse is taking a health history. Which question is the priority?
“When was the last time you visited your primary health care
a. provider?”
b. “Has this condition affected your eating habits in any way?”
c. “What medications are you currently taking?”
d. “Are you able to sleep at night?”
ANS: C
Antibiotics and oral contraceptives can disrupt normal flora in the vagina, causing an overgrowth of Candida
albicans in that area. It is important to ask the patient about current medications to obtain information that may
assist with diagnosis. The body contains normal flora (microorganisms) that live on the surface of skin, saliva,
oral mucosa, gastrointestinal tract, and genitourinary tract. The normal flora of the vagina causes vaginal
secretions to achieve a low pH, inhibiting the growth of many microorganisms. Visiting the primary health care
provider is important for the patient’s health maintenance but is not the priority. Learning about the patient’s
eating and sleeping habits will assist in the plan of care but is not the priority.
4. The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which
signs and symptoms will the nurse assess for to determine if the child is experiencing a localized
inflammatory response?
Malaise, anorexia, enlarged lymph nodes, and increased white blood
a. cells
b. Chest pain, shortness of breath, and nausea and vomiting
c. Dizziness and disorientation to time, date, and place
43
,d. Edema, redness, tenderness, and loss of function
ANS: D
The body’s cellular response to an injury is seen as inflammation. Signs of localized inflammation include
swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of
inflammation include fever, malaise, and anorexia, as well as enlarged lymph nodes and increased white blood
cells. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac alteration.
Dizziness and disorientation to time, date, and place may indicate a neurologic alteration.
5. Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory
response?
a. Vigorous range-of-motion exercises
b. Turn, cough, and deep breathe
c. Orient to date, time, and place
d. Rest, ice, and elevation
ANS: D
Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the
affected body part. One sign of the inflammatory response, particularly after an injury, is swelling or edema.
Resting the affected injured area, using ice as ordered, wrapping the area to provide support—particularly if it
is an extremity—and elevating the injured area will help to decrease swelling or edema. Turning, coughing,
and deep breathing are utilized for postoperative patients and for immobilized patients to help prevent an
infectious process such as pneumonia. Orientation to date, time, and place is an intervention utilized with many
different types of patients who may be confused. Vigorous range of motion would irritate the inflammatory
process. Range of motion is utilized for individuals who need to improve movement of their extremities,
including immobilized patients.
6. The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an
infection?
a. A patient who is in observation for chest pain
b. A patient who has been admitted with dehydration
c. A patient who is recovering from a right total hip surgery
d. A patient who has been admitted for stabilization of heart problems
ANS: C
The patient who is recovering from a right total hip surgery has a large incision from the surgery. This break in
the skin increases the likelihood of infection. Any break in the integrity of the skin and mucous membranes
allows pathogens to enter and exit the body. The patient has had anesthesia, which depresses the respiratory
system and has the potential to decrease the expansion of alveoli and to increase the chance of infection in the
respiratory system. A patient who is having chest pain, experiencing dehydration, or being admitted with heart
problems does not have open incisions that break the skin; therefore, his or her infection risk is lower.
7. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access
(IV) device. Which nursing intervention is a priority in this procedure?
a. Review the procedure with the patient.
b. Position the patient comfortably.
c. Maintain surgical aseptic technique.
, d. Gather available supplies.
ANS: C
2. The nurse is providing an education session to an adult community group about the effects of smoking
on infection. Which information is most important for the nurse to include in the educational session?
a. Smoke from tobacco products clings to your clothing and hair.
b. Smoking affects the cilia lining the upper airways in the lungs.
c. Smoking can affect the color of the patient’s fingernails.
d. Smoking tobacco products can be very expensive.
ANS: B
A normal defense mechanism against infection in the respiratory tract is the cilia lining the upper airways of
the lungs and normal mucus. When a patient inhales a microbe, the cilia and mucus trap the microbe and
sweep them up and out to be expectorated or swallowed. Smoking may alter this defense mechanism and
increase the patient’s potential for infection. Smoking can be expensive, the smell does cling to hair and
clothing, and the tar within the smoke can alter the color of a patient’s nails. This information can be included
in the education but does not constitute the most important point.
3. A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal
area. A nurse is taking a health history. Which question is the priority?
“When was the last time you visited your primary health care
a. provider?”
b. “Has this condition affected your eating habits in any way?”
c. “What medications are you currently taking?”
d. “Are you able to sleep at night?”
ANS: C
Antibiotics and oral contraceptives can disrupt normal flora in the vagina, causing an overgrowth of Candida
albicans in that area. It is important to ask the patient about current medications to obtain information that may
assist with diagnosis. The body contains normal flora (microorganisms) that live on the surface of skin, saliva,
oral mucosa, gastrointestinal tract, and genitourinary tract. The normal flora of the vagina causes vaginal
secretions to achieve a low pH, inhibiting the growth of many microorganisms. Visiting the primary health care
provider is important for the patient’s health maintenance but is not the priority. Learning about the patient’s
eating and sleeping habits will assist in the plan of care but is not the priority.
4. The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which
signs and symptoms will the nurse assess for to determine if the child is experiencing a localized
inflammatory response?
Malaise, anorexia, enlarged lymph nodes, and increased white blood
a. cells
b. Chest pain, shortness of breath, and nausea and vomiting
c. Dizziness and disorientation to time, date, and place
43
,d. Edema, redness, tenderness, and loss of function
ANS: D
The body’s cellular response to an injury is seen as inflammation. Signs of localized inflammation include
swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of
inflammation include fever, malaise, and anorexia, as well as enlarged lymph nodes and increased white blood
cells. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac alteration.
Dizziness and disorientation to time, date, and place may indicate a neurologic alteration.
5. Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory
response?
a. Vigorous range-of-motion exercises
b. Turn, cough, and deep breathe
c. Orient to date, time, and place
d. Rest, ice, and elevation
ANS: D
Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the
affected body part. One sign of the inflammatory response, particularly after an injury, is swelling or edema.
Resting the affected injured area, using ice as ordered, wrapping the area to provide support—particularly if it
is an extremity—and elevating the injured area will help to decrease swelling or edema. Turning, coughing,
and deep breathing are utilized for postoperative patients and for immobilized patients to help prevent an
infectious process such as pneumonia. Orientation to date, time, and place is an intervention utilized with many
different types of patients who may be confused. Vigorous range of motion would irritate the inflammatory
process. Range of motion is utilized for individuals who need to improve movement of their extremities,
including immobilized patients.
6. The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an
infection?
a. A patient who is in observation for chest pain
b. A patient who has been admitted with dehydration
c. A patient who is recovering from a right total hip surgery
d. A patient who has been admitted for stabilization of heart problems
ANS: C
The patient who is recovering from a right total hip surgery has a large incision from the surgery. This break in
the skin increases the likelihood of infection. Any break in the integrity of the skin and mucous membranes
allows pathogens to enter and exit the body. The patient has had anesthesia, which depresses the respiratory
system and has the potential to decrease the expansion of alveoli and to increase the chance of infection in the
respiratory system. A patient who is having chest pain, experiencing dehydration, or being admitted with heart
problems does not have open incisions that break the skin; therefore, his or her infection risk is lower.
7. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access
(IV) device. Which nursing intervention is a priority in this procedure?
a. Review the procedure with the patient.
b. Position the patient comfortably.
c. Maintain surgical aseptic technique.
, d. Gather available supplies.
ANS: C
