ATI RN
foundations of nursing test bank Questions
Question 1 of 5
A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patients care plan addresses the risk of hemorrhage. How should the nurse best monitor the patients postoperative blood loss?
Correct Answer: B
Rationale: The correct answer is B: Count and inspect each perineal pad that the patient uses. This method directly measures postoperative blood loss and allows for accurate monitoring. It provides quantitative data to assess the severity of hemorrhage. A: Having the patient void and have bowel movements using a commode rather than toilet does not directly measure blood loss and may not provide accurate monitoring. C: Swabbing the patient's perineum for the presence of blood is not as accurate as directly counting and inspecting perineal pads. D: Leaving the patient's perineum open to air does not provide a method for quantifying blood loss and may not be as reliable as inspecting perineal pads.
Question 2 of 5
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
Correct Answer: D
Rationale: The correct answer is D: Hold the condom by the cuff upon withdrawal. This is important because holding the condom by the cuff helps prevent any potential spillage of bodily fluids. During withdrawal, holding the condom by the base prevents it from slipping off and minimizes the risk of exposure to sexually transmitted infections. Explanation of why other choices are incorrect: A: Attaching the condom prior to erection is incorrect as it may lead to breakage or slipping off during intercourse. B: Reusing a condom with the same partner is highly discouraged due to the risk of breakage, reduced effectiveness, and potential exposure to infections. C: Using skin lotion as a lubricant is not recommended as it can degrade the condom material, increasing the risk of breakage.
Question 3 of 5
A nurse is using the RESPECT mnemonic to establishrapport, the “R” in RESPECT. Which actions should the nurse take? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Connect on a social level. In the RESPECT mnemonic, "R" stands for "Rapport," which is crucial in building a therapeutic relationship with the patient. Connecting on a social level helps establish trust, empathy, and understanding between the nurse and the patient. This connection can lead to better communication, collaboration, and ultimately improved patient outcomes. Summary: - Choice B: Helping the patient overcome barriers is important but not specifically related to establishing rapport in the RESPECT mnemonic. - Choice C: Suspending judgment is important for effective communication but does not directly address building rapport. - Choice D: Stressing collaboration is valuable but does not specifically focus on connecting on a social level to build rapport.
Question 4 of 5
A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Diabetic retinopathy. This is because diabetic retinopathy is a leading cause of blindness in adults over 40, resulting from diabetes affecting blood vessels in the retina. Trauma (B) is a common cause of visual impairment but not as prevalent as diabetic retinopathy in this age group. Macular degeneration (C) primarily affects older individuals, typically over 50, rather than those over 40. Cytomegalovirus (D) is a cause of blindness in immunocompromised individuals, not specific to the age group mentioned. Glaucoma (E) is a leading cause of blindness worldwide but is more common in older adults and not specifically over 40.
Question 5 of 5
A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
Correct Answer: B
Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction. Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.
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