ATI RN
foundation of nursing questions Questions
Question 1 of 5
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
Correct Answer: B
Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention. Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B. Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B. Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.
Question 2 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.
Question 3 of 5
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
Correct Answer: C
Rationale: The correct answer is C because an older patient with glaucoma is at risk for increased intraocular pressure when receiving an enema. This situation requires immediate attention to prevent potential complications like vision loss. The other choices do not pose immediate risks that require urgent intervention. A and B can wait for a brief period, while D is not time-sensitive in the context of a myocardial infarction. The priority is always given to the patient with the highest risk of harm if the intervention is delayed.
Question 4 of 5
A nurse is caring for a patient who has had diarrheafor the past week. Which additional assessment finding will the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Decreased skin turgor. Diarrhea leads to fluid loss and dehydration, causing a decrease in skin turgor. Assessing skin turgor by gently pinching the skin on the patient's forearm is important to determine hydration status. A: Distended abdomen is more indicative of possible bowel obstruction or fluid accumulation, not specifically related to diarrhea. C: Increased energy levels are unlikely as diarrhea typically causes fatigue and weakness due to electrolyte imbalance. D: Elevated blood pressure is not a typical finding with diarrhea unless there are other underlying medical conditions.
Question 5 of 5
A nurse is providing care to a patient from adifferent culture. Which action by the nurse indicates cultural competence?
Correct Answer: A
Rationale: The correct answer is A because effective communication in a multicultural context is essential for cultural competence. By communicating effectively, the nurse can understand and respect the patient's cultural beliefs, values, and practices. This helps in providing appropriate care tailored to the patient's cultural needs. Choice B is too vague and does not specifically address communication skills. Choice C, visiting a foreign country, does not directly demonstrate cultural competence in patient care. Choice D, speaking a different language, is important but not sufficient on its own to indicate cultural competence without effective communication skills.