ATI RN
foundations of nursing test bank Questions
Question 1 of 5
In determining malnourishment in a patient, which assessment finding is consistent with this disorder?
Correct Answer: C
Rationale: Step 1: Malnourishment often leads to iron deficiency anemia, causing spoon-shaped nails (koilonychia). Step 2: Koilonychia is a classic sign of chronic malnutrition and iron deficiency. Step 3: Moist lips (A) and pink conjunctivae (B) are not specific to malnourishment. Step 4: Not easily plucked hair (D) is more related to hair health rather than malnutrition.
Question 2 of 5
The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do?
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Taper infusion gradually): 1. Tapering the infusion gradually allows for a smooth transition off PN without causing metabolic disturbances. 2. Abruptly stopping PN can lead to hypoglycemia and electrolyte imbalances. 3. Increasing the rate may cause fluid overload or hyperglycemia. 4. Hanging 5% dextrose alone does not provide adequate nutrition and may not meet the patient's needs.
Question 3 of 5
A nurse is caring for a group of patients. Which patient will the nurse seefirst?
Correct Answer: B
Rationale: The correct answer is B because the nurse should prioritize the patient who has been receiving total parenteral nutrition (TPN) infusing with the same tubing for 26 hours. This patient needs to be seen first to monitor for any potential complications or issues related to TPN administration. Choice A can be ruled out because 50 hours is longer than 26 hours. Choices C and D involve enteral feeding, which is important but generally less critical than TPN. Additionally, choice D has a shorter duration than choice B. Therefore, choice B is the most time-sensitive and critical patient to assess first.
Question 4 of 5
A nurse is teaching a patient about the urinarysystem. In which order will the nurse present the structures, following the flow of urine?
Correct Answer: B
Rationale: The correct order is B: Kidney, ureters, bladder, urethra. 1. Kidneys filter blood and produce urine. 2. Ureters transport urine from kidneys to bladder. 3. Bladder stores urine until expelled. 4. Urethra carries urine from bladder out of the body. Other choices are incorrect because they do not follow the anatomical flow of urine through the urinary system.
Question 5 of 5
An 86-year-old patient is experiencing uncontrollableleakage of urine with a strong desire to void and even leaks on the way to the toilet. Whichprioritynursing diagnosiswill the nurse include in the patient’s plan of care?
Correct Answer: B
Rationale: Correct Answer: B - Urge urinary incontinence Rationale: 1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence. 2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage. Incorrect Choices: A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void. C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis. D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.