ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
Fraternal twins are delivered by your Rh-negative patient. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the
Correct Answer: C
Rationale: The correct answer is C: indirect Coombs test of the mother. This test is crucial to determine if the mother has developed antibodies against the Rh-positive blood of twin A, which could lead to hemolytic disease of the newborn in future pregnancies. A direct Coombs test of twin A or twin B is not relevant in this scenario as it does not provide information about the mother's antibody status. Transcutaneous bilirubin levels are used to monitor jaundice in newborns and not related to Rh incompatibility. In summary, the indirect Coombs test of the mother is the most relevant test to assess the risk of hemolytic disease in future pregnancies.
Question 2 of 9
The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, “How much fat should I have? I guess the less fat, the better.” Which information will the nurse include in the teaching session?
Correct Answer: D
Rationale: The correct answer is D: Deficiencies occur when fat intake falls below 10% of daily nutrition. Rationale: 1. Fat is essential for absorption of fat-soluble vitamins (A, D, E, K) and for maintaining healthy cell membranes. 2. Fat provides essential fatty acids (omega-3, omega-6) crucial for brain function and inflammation regulation. 3. Adequate fat intake prevents deficiencies like dry skin, poor wound healing, and hormonal imbalances. 4. A low-fat diet should still include at least 10% of daily nutrition from healthy fats for optimal health. Summary: A: Cholesterol intake is important but not the primary focus for a low-fat diet. B: Fats are significant for health, and extreme low-fat diets can lead to deficiencies. C: While some fats are from external sources, the body needs a minimum amount for proper functioning.
Question 3 of 9
A patient who was pregnant had a spontaneous abortion at approximately 4 weeks’ gestation. At the time of the miscarriage, it was thought that all products of conception were expelled. Two weeks later, the patient presents at the clinic office complaining of “crampy” abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/minute (bpm), and respirations, 20 breaths per minute. Based on this assessment data, what does the nurse anticipate as a clinical diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Uterine infection. The patient's symptoms of crampy abdominal pain, scant serosanguineous vaginal drainage with odor, negative pregnancy test, and vital signs indicating fever, low blood pressure, and irregular pulse suggest an infection. The history of recent miscarriage raises suspicion for retained products of conception leading to infection. Ectopic pregnancy (choice A) would present with different symptoms such as abdominal pain, vaginal bleeding, and positive pregnancy test. Gestational trophoblastic disease (choice C) typically presents with abnormal vaginal bleeding and high levels of hCG. Endometriosis (choice D) is a chronic condition and not related to the acute symptoms described. In summary, the clinical presentation aligns with uterine infection given the patient's history, symptoms, and vital signs.
Question 4 of 9
A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
Correct Answer: C
Rationale: The correct answer is C: Increase the patient's oral fluid intake. This is because severe diarrhea can lead to dehydration, which can be dangerous for patients with HIV infection. By increasing oral fluid intake, the patient can stay hydrated and prevent further complications. Administering antidiarrheal medications on a scheduled basis (Choice A) may provide temporary relief but does not address the underlying issue of dehydration. Encouraging the patient to eat balanced meals (Choice B) and increase activity level (Choice D) may be important for overall health but do not directly address the immediate concern of dehydration caused by severe diarrhea.
Question 5 of 9
A patient has returned to the floor after undergoing a transurethral resection of the prostate (TURP). The patient has a continuous bladder irrigation system in place. The patient tells you he is experiencing bladder spasms and asks what you can do to relieve his discomfort. What is the most appropriate nursing action to relieve the discomfort of the patient?
Correct Answer: D
Rationale: Rationale: Administering a smooth-muscle relaxant is the most appropriate nursing action to relieve bladder spasms post-TURP. The smooth-muscle relaxant helps relax the bladder muscles, reducing spasms and discomfort. Applying a cold compress (choice A) may provide temporary relief but won't address the underlying cause. Notifying the urologist (choice B) is important but not the immediate action for relieving spasms. Irrigating the catheter with normal saline (choice C) may not effectively address the spasms. Administering a smooth-muscle relaxant is the best choice for prompt relief.
Question 6 of 9
Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?
Correct Answer: C
Rationale: The correct answer is C: Fundal height measurement of 18 cm. This finding suggests a hydatidiform mole because it is larger than expected for a 10-week pregnancy due to excessive trophoblastic proliferation. A: Blood pressure is within normal range. B: Nausea is common in early pregnancy and not specific to a mole. D: History of bright red spotting is more indicative of a miscarriage or other complications, not necessarily a mole.
Question 7 of 9
A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?
Correct Answer: C
Rationale: The correct choice is C because if no urine is obtained, it indicates that the catheter is not in the urethra. The nurse should remove the catheter, wipe with alcohol to maintain cleanliness, and reinsert after lubrication to ensure proper placement in the urethra. This step-by-step approach allows for a more accurate catheter insertion and prevents potential complications. Choice A is incorrect as discarding the catheter and starting over without addressing the issue does not solve the problem. Choice B is incorrect as filling the balloon with sterile water is not relevant to the situation of catheter misplacement. Choice D is incorrect as leaving the catheter in the vagina can lead to infection and is not a recommended practice.
Question 8 of 9
After the completion of testing, a childs allergies have been attributed to her familys cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action?
Correct Answer: A
Rationale: The correct answer is A: Removing the cat from the family's home. This is the most effective way to prevent allergic reactions in the child. By removing the source of allergens (cat), the child will be exposed to fewer allergens, leading to a reduction in symptoms. B: Administering OTC antihistamines treats symptoms but does not address the underlying cause of the allergy. C: Keeping the cat restricted from the child's bedroom helps reduce exposure, but allergens can still spread throughout the house. D: Maximizing airflow may help reduce allergens in the air but does not eliminate the source of the allergy.
Question 9 of 9
A patient, who delivered her third child yesterday, has just learned that her two school-age children have contracted chickenpox. What should the nurse tell her?
Correct Answer: D
Rationale: The correct answer is D: She must make arrangements to stay somewhere other than her home until the children are no longer contagious. 1. The patient's newborn is at risk of contracting chickenpox from the infected children. 2. Chickenpox can be severe in newborns due to their immature immune systems. 3. It is crucial to protect the newborn by ensuring they are not exposed to the virus. 4. Staying elsewhere until the children are no longer contagious will prevent transmission to the newborn. Incorrect choices: A: Acyclovir is not recommended for prophylactic treatment in this situation. B: Immunity is not automatically transferred from the mother to the baby for chickenpox. C: Allowing the infected children to visit with precautions is not sufficient to protect the newborn.