ATI RN
foundations of nursing test bank Questions
Question 1 of 5
A nurse is caring for a group of patients. Which patient will the nurse seefirst?
Correct Answer: B
Rationale: The correct answer is B because the nurse should prioritize the patient who has been receiving total parenteral nutrition (TPN) infusing with the same tubing for 26 hours. This patient needs to be seen first to monitor for any potential complications or issues related to TPN administration. Choice A can be ruled out because 50 hours is longer than 26 hours. Choices C and D involve enteral feeding, which is important but generally less critical than TPN. Additionally, choice D has a shorter duration than choice B. Therefore, choice B is the most time-sensitive and critical patient to assess first.
Question 2 of 5
An 86-year-old patient is experiencing uncontrollableleakage of urine with a strong desire to void and even leaks on the way to the toilet. Whichprioritynursing diagnosiswill the nurse include in the patient’s plan of care?
Correct Answer: B
Rationale: Correct Answer: B - Urge urinary incontinence Rationale: 1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence. 2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage. Incorrect Choices: A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void. C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis. D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.
Question 3 of 5
A nurse is reviewing results from a urine specimen.What will the nurse expect to see in a patient with a urinary tract infection?
Correct Answer: D
Rationale: The correct answer is D: Bacteria. In a patient with a urinary tract infection (UTI), bacteria are typically present in the urine due to the infection of the urinary system. Bacteria may be detected through urine culture or microscopic examination. A: Casts are not typically associated with UTIs but can indicate kidney disease. B: Protein in the urine can indicate kidney damage or other issues, not specific to UTIs. C: Crystals in the urine can be normal or indicate specific conditions, but they are not specific to UTIs. In summary, the presence of bacteria in the urine is a key indicator of a UTI, while the other choices are more indicative of different conditions or factors.
Question 4 of 5
A nurse is caring for a patient with a continenturinary reservoir. Which action will the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Teach the patient how to self-cath the pouch. In a continent urinary reservoir, patients need to catheterize the pouch several times a day. This is essential for emptying the urine from the pouch as the ileocecal valve creates a one-way valve. Teaching the patient how to self-catheterize ensures proper and timely drainage, preventing complications like urinary retention. Self-catheterization also empowers the patient to take an active role in managing their continence. Summary of other choices: B: Kegel exercises are ineffective for a patient with a continent urinary reservoir as they do not address the need for catheterization. C: Changing the collection pouch is not the primary action needed for a continent urinary reservoir. Catheterization is essential for drainage. D: The Valsalva technique is not appropriate for voiding in a continent urinary reservoir. Catheterization is the recommended method for emptying the pouch.
Question 5 of 5
Which findings should the nurse follow up on afterremoval of a catheter from a patient? (Select allthat apply.)
Correct Answer: B
Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection. A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal. C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem. D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.