ATI RN
foundations of nursing test bank Questions
Question 1 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 2 of 5
The nurse is planning care for a group of patients.Which task will the nurse assign to the nursing assistive personnel (NAP)?
Correct Answer: C
Rationale: Correct Answer: C - Administering an enema Rationale: Administering an enema is a task that can be safely delegated to nursing assistive personnel (NAP) as it is within their scope of practice and does not require the specialized knowledge and skills of a registered nurse. NAP can be trained to perform enema administration safely and effectively, under the supervision of a nurse. This task involves following a specific procedure and does not require clinical judgment or decision-making. Summary of other choices: A: Performing the first postoperative pouch change - This task involves wound care and assessment, which require the expertise of a registered nurse. B: Maintaining a nasogastric tube - This task involves ongoing assessment, monitoring for complications, and adjustments, which are responsibilities of a registered nurse. D: Digitally removing stool - This task involves invasive procedures and assessment, which are beyond the scope of practice for nursing assistive personnel.
Question 3 of 5
A nurse is checking orders. Which order shouldthe nurse question?
Correct Answer: B
Rationale: The correct answer is B because giving a hypertonic solution enema to a patient with fluid volume excess can worsen the condition by drawing more fluid into the colon. This can lead to further fluid volume overload and electrolyte imbalances. The other choices are incorrect because: A: Normal saline enema is appropriate for constipation. C: Kayexalate enema is used to treat hyperkalemia, not hypokalemia. D: Oil retention enema is indicated for constipation to soften stool.
Question 4 of 5
A nurse is preparing to lavage a patient in theemergency department for an overdose. Which tube should the nurse obtain?
Correct Answer: A
Rationale: The correct answer is A: Ewald tube. This tube is used for gastric lavage due to its large diameter and open end which allows for effective suction of gastric contents. The Ewald tube is specifically designed for gastric lavage and is ideal for removing toxins from the stomach. Summary of why the other choices are incorrect: B: Dobhoff tube is a small-bore feeding tube, not suitable for gastric lavage. C: Miller-Abbott tube is used for intestinal decompression, not gastric lavage. D: Sengstaken-Blakemore tube is used for esophageal varices, not gastric lavage.
Question 5 of 5
A nurse is working at a health fair screening people for liver cancer. Which population group should the nurse monitor mostclosely for liver cancer?
Correct Answer: B
Rationale: The correct answer is B: Asian Americans. Asian Americans have a higher incidence of liver cancer compared to other population groups due to factors such as chronic hepatitis B infection and dietary aflatoxin exposure. Monitoring this group closely is essential for early detection and intervention. Incorrect choices: A: Hispanic - While Hispanics have a higher prevalence of fatty liver disease, the highest risk of liver cancer is not among this group. C: Non-Hispanic Caucasians - Caucasians have a lower incidence of liver cancer compared to Asian Americans. D: Non-Hispanic African-Americans - African-Americans have a lower risk of liver cancer compared to Asian Americans due to differences in risk factors and prevalence of hepatitis B.