ATI RN
foundations of nursing practice questions Questions
Question 1 of 5
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 2 of 5
A nurse is providing care to a patient with anindwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)?
Correct Answer: A
Rationale: The correct answer is A: Drapes the urinary drainage tubing with no dependent loops. This practice helps prevent CAUTI by ensuring that urine does not flow back into the bladder, reducing the risk of infection. Dependent loops can lead to stagnant urine, providing a breeding ground for bacteria. Choice B is incorrect because washing the drainage tube towards the meatus can introduce bacteria into the urinary tract, increasing the risk of infection. Choice C is incorrect because placing the drainage bag on the floor can introduce contaminants from the floor into the system. Choice D is incorrect because allowing the spigot to touch the receptacle can lead to contamination and increase the risk of infection.
Question 3 of 5
The nurse is using different toileting schedules.Which principles will the nurse keep in mind when planning care? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A because habit training involves keeping a bladder diary to identify patterns and develop a toileting schedule. This helps in promoting regular voiding habits. B is incorrect because timed voiding isn't solely based on the patient's urge to void, but rather on a predetermined schedule. C is incorrect as prompted voiding involves reminding patients to use the restroom at regular intervals, not just asking if they are wet or dry. D is incorrect because elevating feet in patients with edema may help reduce swelling but has no direct impact on nighttime voiding.
Question 4 of 5
A patient is using laxatives three times dailyto lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient?
Correct Answer: A
Rationale: The correct answer is A. Long-term laxative use can lead to the bowel becoming less responsive to stimuli, resulting in constipation. This is due to the body becoming dependent on laxatives to stimulate bowel movements. Choice B is incorrect as laxatives typically do not cause trauma or scarring to the intestinal lining. Choice C is incorrect because while emollient laxatives can be helpful for constipation, long-term use is not recommended due to potential side effects. Choice D is incorrect because laxatives do not directly cause malnourishment or prevent waste production.
Question 5 of 5
Massage around the feces and work down to remove.
Correct Answer: A
Rationale: The correct order for the massage is to start around the feces (4), then work downwards (1), followed by moving towards the sides (5), then back to the top (2), continuing to the sides again (3), and finally finishing at the top (6). This sequence ensures a thorough and effective massage process. Other choices have different orders that do not follow the logical flow of massaging around the feces and working down as specified in the question.