ATI RN
test bank foundations of nursing Questions
Question 1 of 9
A nurse is caring for a hospitalized patientwith a urinary catheter. Which nursing actionbestprevents the patient from acquiring an infection?
Correct Answer: A
Rationale: The correct answer is A: Maintaining a closed urinary drainage system. This action prevents infection by reducing exposure to external pathogens. Step 1: A closed system minimizes the risk of contamination. Step 2: It prevents entry of bacteria into the urinary tract. Step 3: Regularly emptying the drainage bag helps maintain a closed system. Step 4: This action promotes patient safety and reduces infection risk. Summary: Choice B (strict clean technique) may reduce infection risk during catheter insertion but does not prevent infections post-insertion. Choice C (replacing drainage bag once per shift) increases infection risk due to frequent disconnection. Choice D (fully inflating catheter balloon) is unrelated to infection prevention.
Question 2 of 9
A patient has been prescribed sildenafil. What should the nurse teach the patient about this medication?
Correct Answer: A
Rationale: The correct answer is A because sildenafil works by enhancing the effects of nitric oxide, which is released during sexual stimulation to relax the muscles in the penis and increase blood flow for an erection. Therefore, sexual stimulation is necessary for the medication to be effective. Explanation of other choices: B: While sildenafil is typically taken 30 minutes to 4 hours before sexual activity, it does not need to be exactly 1 hour prior. C: Facial flushing and headache are common side effects of sildenafil but do not require immediate reporting unless severe or persistent. D: Sildenafil may cause temporary visual disturbances like changes in color vision, but permanent visual changes are rare.
Question 3 of 9
A nurse is caring for a 33-year-old male who has come to the clinic for a physical examination. He states that he has not had a routine physical in 5 years. During the examination, the physician finds that digital rectal examination (DRE) reveals stoney hardening in the posterior lobe of the prostate gland that is not mobile. The nurse recognizes that the observation typically indicates what?
Correct Answer: C
Rationale: The correct answer is C: Evidence of a more advanced lesion. A stoney hardening in the posterior lobe of the prostate gland that is not mobile is indicative of a more advanced lesion, such as prostate cancer. This finding suggests that the lesion has progressed beyond the early stages. In early prostate cancer, the prostate gland may feel firm but not stoney hard, and the lesion is usually mobile. Metastatic disease would involve spread of the cancer to other parts of the body, which is not evident from the DRE alone. A normal finding would not present as stoney hardening and lack of mobility in the prostate gland during a DRE.
Question 4 of 9
A patient with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Pain control. This is the main focus because the patient's quality of life should be prioritized, and managing pain is crucial for comfort and well-being in end-of-life care. Pain can significantly impact the patient's physical and emotional state. The other choices are incorrect because managing treatment complications (B) and administering treatments (E) may not be relevant if the tumor is inoperable and the patient has a short life expectancy. Interpretation of diagnostic tests (C) may not be necessary at this stage, and assistance with self-care (D) may not be the main priority compared to pain control.
Question 5 of 9
A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond?
Correct Answer: C
Rationale: The correct answer is C because it acknowledges that many HIV patients use alternative therapies and emphasizes the importance of weighing the benefits and risks. This response shows respect for the patient's autonomy and preferences while also recognizing the need for informed decision-making. Choice A is incorrect because it dismisses complementary therapies outright without considering individual patient needs or preferences. Choice B is incorrect as it suggests avoiding alternative therapies entirely, which may not align with the patient's wishes or experiences. Choice D is incorrect as it presents a false dichotomy between alternative and medical approaches, disregarding the possibility of integrating both types of treatments.
Question 6 of 9
A child is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. What food items would the nurse inform the parents are common allergens?
Correct Answer: C
Rationale: The correct answer is C: Eggs and wheat. This is because eggs and wheat are common food allergens in children. Eggs contain proteins that can trigger allergic reactions, while wheat contains gluten, a common allergen. Citrus fruits and rice (choice A) are not common allergens. Root vegetables and tomatoes (choice B) are also less likely to cause allergies. Hard cheeses and vegetable oils (choice D) are not commonly associated with food allergies in children. Therefore, informing the parents about eggs and wheat as common allergens is crucial for the child's testing and management of food allergies.
Question 7 of 9
A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patients complaint?
Correct Answer: A
Rationale: The correct answer is A. Postoperative day 6 following tympanoplasty and mastoidectomy is still within the early phase of recovery, where occasional sharp, shooting pains in the affected ear can be expected due to the healing process. Here's a step-by-step rationale: 1. Timing: It is only day 6 post-surgery, so it is normal to experience some pain as part of the healing process. 2. Nature of pain: Sharp, shooting pains are common post-surgery due to tissue healing and nerve regeneration. 3. Lack of other symptoms: The patient did not report any other concerning symptoms like fever or discharge, which would be more indicative of an infection. 4. Unlikely complications: Spontaneous rupture of the tympanic membrane or unsuccessful surgery would typically present with more severe and consistent symptoms. Summary: - B: Unlikely as there are no other signs of infection. - C: Unlikely as the pain is described as occasional and sharp. - D:
Question 8 of 9
A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy?
Correct Answer: D
Rationale: The correct answer is D because patients with lower health literacy, such as those with a high-school diploma, may struggle to understand complex health information. The nurse should assess this patient closely to ensure they comprehend and can follow instructions. Patients with higher education levels (college degree) may have better health literacy skills. Age alone (35 or 68 years old) does not determine health literacy level. It is essential to focus on the patient's educational background to assess their health literacy effectively.
Question 9 of 9
A nurse is providing an educational event to a local mens group about prostate cancer. The nurse should cite an increased risk of prostate cancer in what ethnic group?
Correct Answer: C
Rationale: The correct answer is C: African Americans. African American men have the highest incidence rate of prostate cancer among all ethnic groups. This is due to genetic and environmental factors, as well as disparities in access to healthcare. Native Americans (A), Caucasian Americans (B), and Asian Americans (D) have lower rates of prostate cancer compared to African Americans. It is important to educate the local men's group about this increased risk in African Americans to promote awareness and early detection.