ATI RN
foundation of nursing questions Questions
Question 1 of 9
The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching?
Correct Answer: D
Rationale: The correct answer is D: "Don't blow your nose for 2 to 3 weeks." After mastoid surgery, blowing the nose can increase pressure in the surgical area and disrupt healing. Here's the rationale: 1. Blowing the nose can increase pressure in the surgical area and lead to complications. 2. Avoiding blowing the nose helps prevent infection and reduces the risk of damaging the surgical site. 3. It is essential to follow this instruction to promote proper healing and reduce the chances of postoperative complications. In summary, the other choices are incorrect because inducing a sneeze, exercising, and avoiding side-lying position do not directly relate to the specific care needs after mastoid surgery.
Question 2 of 9
A nurse is assessing a patient who presented to the ED with priapism. The student nurse is aware that this condition is classified as a urologic emergency because of the potential for what?
Correct Answer: C
Rationale: The correct answer is C: Permanent vascular damage. Priapism is a prolonged erection that can lead to ischemia and damage to the penile tissue due to impaired blood flow, potentially resulting in permanent vascular damage. Urinary tract infection (A) is unrelated to priapism. Chronic pain (B) may occur but is not the primary concern. Future erectile dysfunction (D) can result from priapism but is not as immediate or severe as permanent vascular damage. Therefore, C is the most critical consequence to address in priapism.
Question 3 of 9
The nurse on the medicalsurgical unit is reviewing discharge instructions with a patient who has a history of glaucoma. The nurse should anticipate the use of what medications?
Correct Answer: B
Rationale: The correct answer is B: Cholinergics. Glaucoma is a condition characterized by increased intraocular pressure due to impaired drainage of aqueous humor. Cholinergics help to constrict the pupil and improve the outflow of aqueous humor, thus reducing intraocular pressure. This medication class is commonly used to manage glaucoma. A: Potassium-sparing diuretics are not typically used in the treatment of glaucoma. They are mainly used to manage conditions like hypertension and heart failure. C: Antibiotics are not indicated for the routine management of glaucoma. They are used to treat infections. D: Loop diuretics are not commonly used in the treatment of glaucoma. They are primarily used to manage conditions like edema and hypertension.
Question 4 of 9
A nurse is caring for a patient who has had diarrhea for 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, causing dehydration and decreased skin turgor. This indicates the patient's hydration status. A: Distended abdomen is more common in conditions like bowel obstruction, not necessarily in diarrhea. C: Increased energy levels are unlikely due to the patient's weakened state from dehydration. D: Elevated blood pressure is not typically associated with dehydration.
Question 5 of 9
The clinic nurse is performing a prenatal assessment on a pregnant patient at risk for preeclampsia. Which clinical sign would not present as a symptom of preeclampsia?
Correct Answer: C
Rationale: The correct answer is C, Glucosuria. Preeclampsia is characterized by hypertension, proteinuria, and edema. Glucosuria is not a typical symptom of preeclampsia. Glucosuria is more commonly associated with gestational diabetes, which is a separate condition from preeclampsia. Therefore, in a pregnant patient at risk for preeclampsia, the presence of glucosuria would not be indicative of preeclampsia. The other choices, edema, proteinuria, and hypertension, are all common clinical signs seen in patients with preeclampsia.
Question 6 of 9
A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patients health status?
Correct Answer: A
Rationale: Step 1: Serous otitis media is common in children due to eustachian tube dysfunction, not usually related to systemic infections. Step 2: Recurrent infections may indicate age-related changes like decreased eustachian tube function. Step 3: Age-related physiologic changes can lead to poor drainage, causing recurrent otitis media. Step 4: Therefore, choice A is correct as it aligns with the typical presentation of serous otitis media in the context of age. Summary: Choice B is incorrect as there is no indication for temporary mobility restriction. Choice C is incorrect as serous otitis media does not typically warrant assessment for nasopharyngeal cancer. Choice D is incorrect as blood cultures are not typically indicated for serous otitis media.
Question 7 of 9
The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is themostlikely cause of the diarrhea?
Correct Answer: C
Rationale: The correct answer is C: Formula intolerance. When a patient develops diarrhea shortly after starting enteral feeding, formula intolerance is the most likely cause. This can occur due to the patient's inability to tolerate certain ingredients in the formula, leading to gastrointestinal upset. Antibiotics (choice A) and Clostridium difficile (choice B) typically take longer to cause diarrhea. Bacterial contamination (choice D) would usually result in more severe symptoms beyond just diarrhea. In this scenario, formula intolerance is the most logical explanation for the immediate onset of diarrhea after starting enteral feeding.
Question 8 of 9
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patients care, what nursing diagnosis should be prioritized?
Correct Answer: D
Rationale: The correct answer is D: Risk for Impaired Gas Exchange Related to Airway Obstruction. This should be prioritized because hereditary angioedema can lead to swelling in the airway, potentially causing respiratory distress and compromising gas exchange. This nursing diagnosis addresses the immediate threat to the patient's respiratory function. A: Risk for Infection Related to Skin Sloughing - While skin sloughing can occur with hereditary angioedema, it is not the priority over ensuring adequate gas exchange. B: Risk for Acute Pain Related to Loss of Skin Integrity - Pain management is important, but addressing airway obstruction takes precedence due to the potential for respiratory compromise. C: Risk for Impaired Skin Integrity Related to Cutaneous Lesions - Skin integrity issues may be present but do not pose as immediate a threat as airway obstruction.
Question 9 of 9
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement. Summary of Incorrect Choices: A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach. B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage. D: Measuring from the tip of the nose to the earlobe to