ATI RN
foundations of nursing practice questions Questions
Question 1 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 2 of 9
A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, When I was young I used to take antihistamines, but they always put me to sleep. How should the nurse best respond?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. The newer antihistamines, such as second-generation antihistamines like loratadine or cetirizine, are designed to cause less sedation compared to older antihistamines like diphenhydramine. 2. These newer antihistamines have a lower affinity for crossing the blood-brain barrier, reducing the sedative effects. 3. Therefore, suggesting that the newer antihistamines are different and cause less sedation is the best response to address the patient's concerns. Summary of Incorrect Choices: A. While some newer antihistamines may be combined with decongestants to offset drowsiness, this is not a consistent feature of all newer antihistamines. B. Developing tolerance to sedation after a few months is not a common or reliable response to antihistamines. D. Taking antihistamines at bedtime may help with sedation, but it does not address
Question 3 of 9
A patient with end-stage heart failure has participated in a family meeting with the interdisciplinary team and opted for hospice care. On what belief should the patients care in this setting be based
Correct Answer: C
Rationale: The correct answer is C: Meaningful living during terminal illness is best supported in the home. This is because hospice care focuses on providing compassionate care and support in the comfort of the patient's own home, which can enhance quality of life and dignity. Being in a familiar and comfortable environment allows the patient to receive personalized care and emotional support from family members. Options A, B, and D are incorrect because hospice care emphasizes comfort and quality of life over technologic interventions, designated facilities, and prolonging physiologic dying. Ultimately, the goal of hospice care is to prioritize the patient's emotional and physical well-being during the end stages of life.
Question 4 of 9
A patient who is scheduled for an open prostatectomy is concerned about the potential effects of the surgery on his sexual function. What aspect of prostate surgery should inform the nurses response?
Correct Answer: B
Rationale: Step 1: Prostate surgery can damage nerves responsible for erectile function. Step 2: Nerve damage can lead to erectile dysfunction post-prostatectomy. Step 3: Choice B correctly states that all prostatectomies carry a risk of nerve damage and consequent erectile dysfunction, aligning with the potential impact of surgery on sexual function. Step 4: Other choices lack accuracy: A incorrectly attributes erectile dysfunction solely to hormonal changes, C falsely suggests temporary nature of dysfunction, and D wrongly claims no risk of dysfunction due to modern techniques.
Question 5 of 9
The nurse is caring for a patient has just been given a 6-month prognosis following a diagnosis of extensive stage small-cell lung cancer. The patient states that he would like to die at home, but the team believes that the patients care needs are unable to be met in a home environment. What might you suggest as an alternative?
Correct Answer: D
Rationale: The correct answer is D: Discuss a referral for hospice care. Hospice care provides specialized care for patients with terminal illnesses, focusing on comfort and quality of life. This option aligns with the patient's wish to die at home and ensures his care needs are met. Hospice care also provides emotional and spiritual support for both the patient and family. A: Discuss a referral for rehabilitation hospital - This option focuses on rehabilitation, which is not suitable for a patient with a terminal illness like extensive stage small-cell lung cancer. B: Panel the patient for a personal care home - Personal care homes may not provide the level of specialized care needed for a terminally ill patient. C: Discuss a referral for acute care - Acute care is more focused on treating acute illnesses and injuries, not providing end-of-life care for a patient with a terminal illness.
Question 6 of 9
One aspect of the nurses comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would the nurse identify as a hope-fostering category?
Correct Answer: A
Rationale: The correct answer is A: Uplifting memories. When assessing hope in a terminally ill patient, identifying uplifting memories can foster hope by providing emotional support, positive experiences, and a sense of purpose. Memories can inspire optimism and comfort in difficult times. B: Ignoring negative outcomes is incorrect as it does not address the patient's emotional needs or promote coping strategies. C: Envisioning one specific outcome is incorrect because hope should encompass a range of possibilities, not just one specific outcome. D: Avoiding an actual or potential threat is incorrect as it focuses on avoidance rather than on promoting positive emotions and psychological well-being.
Question 7 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 8 of 9
A nurse is teaching a health class about the nutritional requirements throughout the life span. Which information should the nurse include in the teaching session? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A because infants typically triple their birth weight by 1 year of age due to rapid growth and development. This information is crucial for understanding normal growth patterns in infants. Choice B is incorrect as picky eating behavior is common in toddlers but not a universal characteristic. Choice C is incorrect as school-age children can consume hot dogs and grapes safely as long as they are cut into appropriate sizes to prevent choking hazards. Choice D is incorrect as breastfeeding women actually need an additional 450-500 kcal/day, not 750 kcal/day.
Question 9 of 9
The nurses assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patients visual acuity?
Correct Answer: B
Rationale: The correct answer is B because the patient's inability to count fingers indicates severe visual impairment. Testing hand motion perception is a more appropriate initial assessment for patients with such significant visual losses. This method can differentiate between light perception and no light perception, providing valuable information about the patient's visual acuity. The other choices are incorrect because assessing vision using a Snellen chart (A) requires more visual acuity than just being able to see hand motion. Performing a detailed examination of external eye structures (C) and palpating periocular regions (D) are not relevant for assessing visual acuity and do not provide information on the patient's ability to perceive hand motion.