ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
A nurse has taught the patient how to use crutches.The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the “I” in PIE charting?
Correct Answer: C
Rationale: Correct Answer: C - Used crutches with no difficulties Rationale: 1. "Used crutches with no difficulties" reflects the patient's successful application of the taught skill. 2. This information indicates the patient's ability to independently perform the task. 3. It demonstrates the effectiveness of the teaching provided by the nurse. 4. "Used crutches with no difficulties" is a specific and objective observation of the patient's performance. Summary: A. "Patient went up and down stairs" is too general and does not indicate the patient's proficiency. B. "Demonstrated use of crutches" does not confirm the patient's actual performance. D. "Deficient knowledge related to never using crutches" is incorrect as it does not reflect the patient's successful use of crutches.
Question 2 of 9
A patient has just returned to the floor following a transurethral resection of the prostate. A triple- lumen indwelling urinary catheter has been inserted for continuous bladder irrigation. What, in addition to balloon inflation, are the functions of the three lumens?
Correct Answer: A
Rationale: The correct answer is A: Continuous inflow and outflow of irrigation solution. The first lumen inflates the balloon to secure the catheter in place. The second lumen allows continuous inflow of irrigation solution to prevent clot formation. The third lumen allows continuous outflow to ensure the bladder is continuously irrigated. Choices B, C, and D are incorrect because they do not accurately describe the functions of the three lumens in a transurethral resection of the prostate procedure.
Question 3 of 9
A nurse is caring for a male patient with urinaryretention. Which action should the nurse takefirst?
Correct Answer: C
Rationale: The correct answer is C: Assist to a standing position. This action helps utilize gravity to aid in emptying the bladder and may help the patient void without the need for invasive measures like catheterization or medications. It is a non-invasive and natural approach to promote urination. Limiting fluid intake (A) could worsen the situation by concentrating urine and worsening retention. Inserting a urinary catheter (B) should be considered only if other measures fail. Asking for a diuretic medication (D) does not address the immediate need for bladder emptying and may not be necessary if the patient can void naturally.
Question 4 of 9
A man tells the nurse that his father died of prostate cancer and he is concerned about his own risk of developing the disease, having heard that prostate cancer has a genetic link. What aspect of the pathophysiology of prostate cancer would underlie the nurses response?
Correct Answer: A
Rationale: The correct answer is A because several studies have indeed shown an association between BRCA-2 mutation and an increased risk of prostate cancer. BRCA-2 mutation is known to be linked to an increased risk of various cancers, including prostate cancer. This genetic mutation can be inherited and passed down through generations, leading to a higher likelihood of developing prostate cancer. Choices B, C, and D are incorrect because: B: HNPCC (Hereditary Nonpolyposis Colorectal Cancer) is not specifically associated with prostate cancer, and it is not an autosomal dominant mutation causing prostate cancer in men. C: TP53 gene is associated with other types of cancers, such as breast cancer, but not strongly linked to prostate cancer. D: Research has shown that genetics do play a role in the development of prostate cancer, contradicting the statement that genetics are unrelated to the disease.
Question 5 of 9
A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurses priority for care?
Correct Answer: B
Rationale: The correct answer is B: Protect the patient's airway. In anaphylaxis, airway compromise can lead to respiratory distress and even respiratory arrest. The priority is to ensure the patient has a patent airway to maintain oxygenation. This can be achieved through interventions such as positioning, oxygen therapy, and potentially intubation if needed. Monitoring the patient's level of consciousness (A) is important but secondary to ensuring airway patency. Providing psychosocial support (C) is not the immediate priority in anaphylaxis. Administering medications (D) is also important but only after ensuring the airway is protected.
Question 6 of 9
The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient, what characteristic symptom would the nurse expect to find?
Correct Answer: A
Rationale: Step-by-step rationale for why A is correct: 1. Retinal detachment causes traction on the retina. 2. Traction on the retina can stimulate photoreceptors. 3. Stimulation of photoreceptors can lead to perception of flashing lights. 4. Therefore, the characteristic symptom of retinal detachment is flashing lights in the visual field. Summary: B: Sudden eye pain is not a characteristic symptom of retinal detachment. C: Loss of color vision is not typically associated with retinal detachment. D: Colored halos around lights are more indicative of conditions like glaucoma or corneal edema, not retinal detachment.
Question 7 of 9
Which action indicates the nurse is meeting aprimary goal of cultural competent care for patients?
Correct Answer: C
Rationale: The correct answer is C because providing individualized care is a fundamental aspect of cultural competence. This means tailoring care to meet the unique cultural, social, and personal needs of each patient. It involves understanding and respecting a patient's beliefs, values, and practices. Explanation: A. Providing care to transgender patients is important, but it is not the primary goal of cultural competence. B. Restoring relationships is beneficial but may not directly address cultural competence. D. Providing care to surgical patients is a common nursing duty but does not specifically relate to cultural competence.
Question 8 of 9
Traditionally, nurses have been involved with tertiary cancer prevention. However, an increasing emphasis is being placed on both primary and secondary prevention. What would be an example of primary prevention?
Correct Answer: C
Rationale: The correct answer is C: Teaching patients to wear sunscreen, which is an example of primary prevention. Primary prevention aims to prevent the occurrence of a disease before it occurs by addressing risk factors. In this case, teaching patients to wear sunscreen helps prevent skin cancer by reducing exposure to harmful UV rays. Yearly Pap tests (A) are a secondary prevention measure for cervical cancer, detecting precancerous changes. Testicular self-examination (B) is a form of secondary prevention for testicular cancer, aiming to detect any abnormalities early. Screening mammograms (D) are also a secondary prevention measure for breast cancer, detecting tumors at an early stage.
Question 9 of 9
On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Cholesteatoma. A red blemish behind the tympanic membrane is indicative of a cholesteatoma, which is a noncancerous cyst in the middle ear. This occurs due to the accumulation of skin cells and debris in the middle ear space. Other choices (A, C, D) are not associated with a red blemish on otoscopy. An acoustic tumor (A) typically presents as a slow-growing mass on the vestibulocochlear nerve. Facial nerve neuroma (C) involves the facial nerve and does not typically cause a red blemish. Glomus tympanicum (D) is a vascular tumor arising from the middle ear but does not usually present as a red blemish.