ATI RN
foundation of nursing questions Questions
Question 1 of 5
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
Correct Answer: B
Rationale: The correct answer is B: Thigh. When administering epinephrine during an anaphylactic reaction, the thigh is the recommended site due to its large muscle mass and quick absorption rate. Steps: 1. Remove safety cap. 2. Firmly push the auto-injector against the thigh until it clicks. 3. Hold in place for a few seconds. 4. Seek medical help immediately. Rationale for incorrect choices: A: Forearm - Not recommended due to smaller muscle mass and slower absorption. C: Deltoid muscle - Not preferred as it may not provide as rapid absorption as the thigh. D: Abdomen - Not ideal due to potential fat layers that could affect absorption speed.
Question 2 of 5
A patient has returned to the floor from the PACU after undergoing a suprapubic prostatectomy. The nurse notes significant urine leakage around the suprapubic tube. What is the nurses most appropriate action?
Correct Answer: B
Rationale: The correct answer is B: Inform the urologist of this finding. In this scenario, significant urine leakage around the suprapubic tube indicates a potential issue with the tube placement or functioning. It is crucial to involve the urologist, who is the specialist managing the patient's urological interventions, to assess and address the cause of the leakage promptly. This action ensures timely and appropriate intervention to prevent complications such as infection or further damage. Choice A is incorrect because simply cleansing the skin does not address the underlying issue of urine leakage. Choice C is incorrect and potentially harmful as removing the suprapubic tube without professional assessment can lead to serious complications. Choice D is incorrect as administering antispasmodic drugs may not be the appropriate action without further evaluation by the urologist.
Question 3 of 5
A patient has undergone diagnostic testing and has been diagnosed with otosclerosis? What ear structure is primarily affected by this diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Stapes. Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, causing the stapes bone to become fixed in place. This results in hearing loss due to the inability of the stapes to transmit sound vibrations to the inner ear. The malleus (choice A), incus (choice C), and tympanic membrane (choice D) are not primarily affected by otosclerosis. The malleus and incus are located in the middle ear but are not typically affected by otosclerosis. The tympanic membrane is part of the outer ear and is not directly involved in otosclerosis.
Question 4 of 5
When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?
Correct Answer: C
Rationale: The correct answer is C: Invasion of the uterine wall by endometrial tissue. Adenomyosis is a condition where endometrial tissue grows into the muscular wall of the uterus, causing symptoms like heavy menstrual bleeding and severe cramping. This process results in inflammation, thickening of the uterine wall, and can lead to enlargement of the uterus. Choice A: Loss of muscle tone in the vaginal wall is incorrect because adenomyosis does not involve the vaginal wall. Choice B: Excessive synthesis and release of unopposed estrogen is incorrect because although estrogen can contribute to the growth of endometrial tissue, it is not the primary pathophysiologic process in adenomyosis. Choice D: Proliferation of tumors in the uterine wall is incorrect because adenomyosis does not involve the growth of tumors, but rather the infiltration of endometrial tissue into the uterine muscle.
Question 5 of 5
A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?
Correct Answer: D
Rationale: Rationale: Option D is correct because raising the head of the bed promotes a more natural position for defecation, allowing gravity to assist. This position helps align the rectum and anal canal, making it easier for the patient to have a bowel movement. Administering laxatives (Option C) may help, but adjusting the bed position is a non-invasive and more immediate intervention. Withholding pain medication (Option B) could lead to unnecessary discomfort for the patient. Administering a barium enema (Option A) is not indicated for addressing difficulty with defecation.