ATI RN
foundations of nursing test bank 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 (NAP)?
Correct Answer: C
Rationale: Correct Answer: C - Administering an enema Rationale: Administering an enema is a task that can be safely delegated to nursing assistive personnel (NAP) as it is within their scope of practice and does not require the specialized knowledge and skills of a registered nurse. NAP can be trained to perform enema administration safely and effectively, under the supervision of a nurse. This task involves following a specific procedure and does not require clinical judgment or decision-making. Summary of other choices: A: Performing the first postoperative pouch change - This task involves wound care and assessment, which require the expertise of a registered nurse. B: Maintaining a nasogastric tube - This task involves ongoing assessment, monitoring for complications, and adjustments, which are responsibilities of a registered nurse. D: Digitally removing stool - This task involves invasive procedures and assessment, which are beyond the scope of practice for nursing assistive personnel.
Question 2 of 5
Which maternal condition always necessitates delivery by cesarean birth?
Correct Answer: B
Rationale: The correct answer is B: Total placenta previa. In this condition, the placenta completely covers the cervix, posing a risk of severe bleeding during vaginal delivery. Cesarean birth is necessary to avoid potential life-threatening complications for both the mother and the baby. Partial abruptio placentae (choice A) involves premature separation of the placenta, but it doesn't always require a cesarean birth. Ectopic pregnancy (choice C) occurs when the fertilized egg implants outside the uterus, typically requiring surgical intervention but not always a cesarean birth. Eclampsia (choice D) is a serious condition characterized by high blood pressure and seizures, but it doesn't always necessitate cesarean birth unless there are other complications that require it.
Question 3 of 5
A nurse is preparing to lavage a patient in theemergency department for an overdose. Which tube should the nurse obtain?
Correct Answer: A
Rationale: The correct answer is A: Ewald tube. This tube is used for gastric lavage due to its large diameter and open end which allows for effective suction of gastric contents. The Ewald tube is specifically designed for gastric lavage and is ideal for removing toxins from the stomach. Summary of why the other choices are incorrect: B: Dobhoff tube is a small-bore feeding tube, not suitable for gastric lavage. C: Miller-Abbott tube is used for intestinal decompression, not gastric lavage. D: Sengstaken-Blakemore tube is used for esophageal varices, not gastric lavage.
Question 4 of 5
A patient with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the patient about this treatment?
Correct Answer: B
Rationale: Step 1: Immunotherapy injections can cause allergic reactions. Step 2: Monitoring post-injection is crucial to detect and manage any potential adverse reactions promptly. Step 3: Staying in the clinic for 30 minutes allows for immediate intervention if needed. Step 4: This ensures patient safety and reduces the risk of severe reactions. Summary: A: Epinephrine is not typically given before immunotherapy injections. C: Therapeutic response may take longer than 3 months to show. D: Immunotherapy is usually given via subcutaneous route, not intravenous.
Question 5 of 5
A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?
Correct Answer: A
Rationale: The correct answer is A: Platelet count of 50,000/mcL. HELLP syndrome is a severe form of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. In this scenario, a platelet count of 50,000/mcL indicates thrombocytopenia, which is a key component of HELLP syndrome. Low platelet count can lead to bleeding complications and is a critical indicator of the syndrome. Choices B, C, and D are incorrect. B: Liver enzyme levels within normal range do not necessarily indicate the presence of HELLP syndrome, as elevated liver enzymes are a hallmark feature of the syndrome. C: Being negative for edema is not a reliable indicator of HELLP syndrome, as edema is a common finding in preeclampsia but not specific to HELLP syndrome. D: No evidence of nausea or vomiting is not a specific sign of HELLP syndrome, as these
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