ATI RN
foundation of nursing questions Questions
Question 1 of 5
The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?
Correct Answer: A
Rationale: The correct answer is A because measuring capillary blood glucose level is a task that can be safely delegated to nursing assistive personnel. This task is within their scope of practice and does not require specialized nursing knowledge. Nursing assistive personnel can perform this task accurately with proper training and supervision. Incorrect choices: B: Measuring nasoenteric tube for insertion requires specialized training and assessment skills that nursing assistive personnel may not possess. C: Measuring pH in gastrointestinal aspirate involves interpretation and clinical judgment that should be done by a licensed nurse. D: Measuring the patient's risk for aspiration involves critical thinking and assessment skills that are beyond the scope of nursing assistive personnel.
Question 2 of 5
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
Question 3 of 5
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 4 of 5
The patient with cardiovascular disease is receiving dietary instructions from the nurse. Which information from the patient indicates teaching is successful?
Correct Answer: B
Rationale: Correct Answer: B - Eat fish at least 5 times per week. Rationale: 1. Fish is rich in omega-3 fatty acids, which are beneficial for heart health. 2. Eating fish frequently can help reduce the risk of cardiovascular diseases. 3. Consuming fish aligns with dietary recommendations for cardiovascular health. Summary of Incorrect Choices: A: Maintaining carbohydrate intake is important, but it may not specifically indicate success in cardiovascular disease management. C: Limiting trans fats is crucial, but it alone may not indicate overall success in dietary management for cardiovascular disease. D: Avoiding high-fiber foods is not recommended, as fiber is beneficial for heart health and overall well-being.
Question 5 of 5
The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient which teaching points? (Select all that apply.)
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Increasing physical activity helps in maintaining a healthy weight and overall health. 2. Regular exercise can reduce the risk of chronic diseases like heart disease and diabetes. 3. Physical activity improves mental health and overall well-being. 4. Exercise boosts immunity and helps in managing stress levels. Summary of why other choices are incorrect: B. Keeping total fat intake to 10% or less is a specific dietary recommendation and not a comprehensive approach to staying healthy. C. Maintaining body weight in a healthy range is important but does not encompass all aspects of staying healthy. D. Choosing and preparing foods with little salt is a specific dietary recommendation and does not address the importance of physical activity in staying healthy.