ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
A patient is 24 hours postoperative following prostatectomy and the urologist has ordered continuous bladder irrigation. What color of output should the nurse expect to find in the drainage bag?
Correct Answer: A
Rationale: The correct answer is A: Red wine colored. Following a prostatectomy, continuous bladder irrigation is commonly used to prevent blood clots and ensure urine drainage. The output is expected to be red wine colored, indicating the presence of blood in the urine due to surgical trauma. Tea-colored (choice B) or amber (choice C) are not specific enough and do not accurately reflect the expected bloody output. Light pink (choice D) may suggest a lower level of bleeding compared to red wine color, but it is not the most accurate description for post-prostatectomy drainage.
Question 2 of 9
A patient has just returned to the floor following a transurethral resection of the prostate. A triple- lumen indwelling urinary catheter has been inserted for continuous bladder irrigation. What, in addition to balloon inflation, are the functions of the three lumens?
Correct Answer: A
Rationale: The correct answer is A: Continuous inflow and outflow of irrigation solution. The first lumen inflates the balloon to secure the catheter in place. The second lumen allows continuous inflow of irrigation solution to prevent clot formation. The third lumen allows continuous outflow to ensure the bladder is continuously irrigated. Choices B, C, and D are incorrect because they do not accurately describe the functions of the three lumens in a transurethral resection of the prostate procedure.
Question 3 of 9
A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy?
Correct Answer: B
Rationale: The correct answer is B: Addressing possible barriers to adherence. This is crucial because adherence to the antiretroviral drug regimen is key for successful therapy in HIV patients. By identifying and addressing barriers such as medication side effects, cost, or forgetfulness, nurses can help patients stay on track with their treatment. Other choices are incorrect: A: Promoting complementary therapies is not the priority in initiating antiretroviral therapy. Adherence to the prescribed regimen is more critical. C: Educating about the pathophysiology of HIV is important, but it may not directly impact the success of the therapy as much as addressing adherence barriers. D: While follow-up blood work is necessary, it is not as immediate and impactful as addressing adherence barriers at the beginning of therapy.
Question 4 of 9
The nurse is providing preoperative education for a patient diagnosed with endometriosis. A hysterectomy has been scheduled. What education topic should the nurse be sure to include for this patient?
Correct Answer: D
Rationale: The correct answer is D because it addresses a crucial aspect of preoperative care for a patient undergoing a hysterectomy due to endometriosis. Emptying the bladder before surgery helps prevent urinary retention postoperatively. Placing a catheter during surgery ensures proper drainage and prevents bladder distention. This education topic is essential for the patient's comfort and well-being during and after the procedure. Choices A, B, and C are incorrect: A: Menstrual periods will not continue after a hysterectomy as the uterus is removed. B: Normal activity is usually restricted after a hysterectomy to promote healing. C: Hormone levels are affected after a hysterectomy, especially if the ovaries are also removed.
Question 5 of 9
A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss?
Correct Answer: C
Rationale: The correct answer is C: Whisper test. The nurse can perform a whisper test by whispering a series of numbers or words at a distance from the child to see if they can repeat them accurately. If the child struggles to hear and repeat the whispered words, it could indicate hearing loss. Rationale: A: Audiometry is a comprehensive hearing test that measures the range and sensitivity of hearing, not suitable for a quick preliminary assessment. B: Rinne test and D: Weber test are both tuning fork tests used to assess conductive and sensorineural hearing loss, not ideal for a quick initial screening of hearing loss. Summary: The Whisper test is the most suitable choice as it provides a quick and simple way to preliminarily assess hearing loss by evaluating the child's ability to hear and repeat whispered sounds accurately.
Question 6 of 9
In which situation would a dilation and curettage (D&C) be indicated?
Correct Answer: B
Rationale: The correct answer is B because an incomplete abortion at 16 weeks may require a D&C to remove remaining tissue to prevent infection and complications. Incomplete abortion means not all fetal tissue has been expelled, posing a risk. Choice A (complete abortion at 8 weeks) does not require a D&C as all tissue is expelled. Choice C (threatened abortion at 6 weeks) does not necessitate immediate intervention. Choice D (incomplete abortion at 10 weeks) is not the best choice as the risk of complications increases with gestational age.
Question 7 of 9
The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads in the electronic health record that the patient has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem?
Correct Answer: B
Rationale: The correct answer is B: Impaired wound healing. Radiation therapy can lead to damage to the skin and blood vessels, affecting wound healing. The nurse should prioritize assessing the patient's skin integrity and any signs of impaired wound healing to prevent complications post-surgery. A: Cognitive deficits - While radiation therapy can impact cognitive function in some cases, it is not the most immediate concern related to surgery post-radiation therapy. C: Cardiac tamponade - Although radiation therapy can increase the risk of heart-related issues, such as pericarditis, cardiac tamponade is a rare and acute complication that is not the most likely immediate concern post-radiation therapy. D: Tumor lysis syndrome - This syndrome is more commonly seen in patients undergoing chemotherapy rather than radiation therapy. It is not typically a concern immediately post-radiation therapy.
Question 8 of 9
A patients most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and liver. What is the most likely mechanism by which the patients cancer cells spread?
Correct Answer: A
Rationale: The correct answer is A: Hematologic spread. In this case, the cancer cells have traveled through the bloodstream to reach the bones and liver. This process is known as hematologic spread, where cancer cells enter the blood vessels and spread to distant organs. Lymphatic circulation (B) involves the spread of cancer cells through the lymphatic system, which is less likely in this scenario. Invasion (C) refers to cancer cells infiltrating nearby tissues, not distant organs. Angiogenesis (D) is the process of new blood vessel formation to support tumor growth, but it does not explain the spread of cancer cells to other organs.
Question 9 of 9
In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share?
Correct Answer: D
Rationale: The correct answer is D because saturated fats are primarily found in animal sources such as red meat, poultry, and dairy products. It is important to limit the intake of saturated fats on a low-fat diet to reduce the risk of heart disease and other health issues. A: Polyunsaturated fats are actually considered healthy fats and should not be restricted to less than 7% of total calories. B: Transfat is a type of unhealthy fat that should be avoided altogether, not just limited to 7% of total calories. C: Unsaturated fats are actually found mostly in plant-based sources like nuts, seeds, and avocados, not animal sources. In summary, choice D is correct because it provides accurate information about the source of saturated fats in animal products, while the other choices provide incorrect or misleading information about different types of fats.