ATI RN
test bank foundations of nursing Questions
Question 1 of 9
The nurse is preparing to check the gastric aspirate for pH. Which equipment will the nurse obtain?
Correct Answer: A
Rationale: The correct answer is A: 10-mL Luer-Lok syringe. The nurse should use this syringe to obtain a gastric aspirate for pH testing because it allows for accurate measurement of the aspirate volume. Asepto syringe (B) is not suitable for this purpose as it is not designed for accurate measurement. Sterile gloves (C) and double gloves (D) are not equipment used specifically for obtaining gastric aspirate for pH testing. Sterile gloves are used for infection control, and double gloves are used for additional protection during procedures.
Question 2 of 9
A nurse is caring for a hospitalized patientwith a urinary catheter. Which nursing actionbestprevents the patient from acquiring an infection?
Correct Answer: A
Rationale: The correct answer is A: Maintaining a closed urinary drainage system. This action prevents infection by reducing exposure to external pathogens. Step 1: A closed system minimizes the risk of contamination. Step 2: It prevents entry of bacteria into the urinary tract. Step 3: Regularly emptying the drainage bag helps maintain a closed system. Step 4: This action promotes patient safety and reduces infection risk. Summary: Choice B (strict clean technique) may reduce infection risk during catheter insertion but does not prevent infections post-insertion. Choice C (replacing drainage bag once per shift) increases infection risk due to frequent disconnection. Choice D (fully inflating catheter balloon) is unrelated to infection prevention.
Question 3 of 9
A nurse is reviewing urinary laboratory results.Which finding will cause the nurse to follow up?
Correct Answer: A
Rationale: The correct answer is A because a protein level of 2 mg/100 mL in urine indicates proteinuria, which can be a sign of kidney dysfunction or other underlying health issues. The nurse should follow up to assess further for possible kidney disease or other conditions. Choice B is not a cause for concern as a urine output of 80 mL/hr is within the normal range. Choice C indicates concentrated urine, which may be due to dehydration but does not necessarily require immediate follow-up. Choice D is within the normal range for urine pH and does not typically warrant immediate follow-up.
Question 4 of 9
A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority?
Correct Answer: C
Rationale: The correct answer is C: Promote positive nitrogen balance. In a postsurgical patient, promoting positive nitrogen balance is crucial for wound healing and tissue repair. This goal helps prevent muscle wasting and promotes overall recovery. A: Reduce dependent nitrogen balance is incorrect as it does not address the need for positive nitrogen balance in wound healing. B: Maintain negative nitrogen balance is incorrect because negative nitrogen balance indicates a loss of protein stores, which is detrimental for healing. D: Facilitate neutral nitrogen balance is incorrect as it does not actively support the increased protein needs for wound repair.
Question 5 of 9
A patients ocular tumor has necessitated enucleation and the patient will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the patients discharge education?
Correct Answer: A
Rationale: The correct answer is A: Disturbed body image. Enucleation can have a significant impact on a patient's self-image and self-esteem. By addressing this nursing diagnosis, the nurse can help the patient cope with the changes in their physical appearance and support them in adjusting to wearing a prosthesis. Summary: - Choice B (Chronic pain) is incorrect because enucleation may cause acute pain initially, but chronic pain is not a common concern post-enucleation. - Choice C (Ineffective protection) is incorrect because enucleation does not necessarily affect the eye's protection mechanism. - Choice D (Unilateral neglect) is incorrect as it refers to a neurological condition unrelated to the patient's situation post-enucleation.
Question 6 of 9
A nurse is preparing a patient for a magneticresonance imaging (MRI) scan. Which nursing action ismostimportant?
Correct Answer: D
Rationale: Correct Answer: D - Removing all of the patient’s metallic jewelry. Rationale: 1. Safety: Metallic objects can be attracted by the MRI magnet, causing harm to the patient and disrupting the imaging process. 2. Artifact Prevention: Metallic objects can produce artifacts on the MRI images, affecting the diagnostic quality. 3. Patient Comfort: Removing jewelry ensures the patient's comfort during the scan, avoiding discomfort or injury. Summary of Incorrect Choices: A: Not eating or drinking before an MRI is important, but it is not the most crucial action compared to patient safety and image quality. B: Colon cleansing may be necessary for certain types of MRI scans, but it is not universally required and is not the most important action. C: Pain medication may be important for patient comfort, but it is not essential for the actual MRI procedure and does not impact safety or image quality.
Question 7 of 9
A patient with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor location precludes the use of enteral feeding. What intervention should the nurse identify as best meeting this patients nutritional needs?
Correct Answer: B
Rationale: The correct answer is B: TPN administered via a peripherally inserted central catheter. TPN provides comprehensive nutrition intravenously, bypassing the GI tract, which is important for patients unable to tolerate oral intake. A peripherally inserted central catheter allows for long-term TPN administration. A: Administration of parenteral feeds via a peripheral IV is not ideal for long-term nutrition as it may not provide complete nutrition. C: Insertion of an NG tube may not be feasible due to the tumor location and the patient's inability to tolerate oral intake. D: Maintaining NPO status and IV hydration alone may lead to malnutrition over time as it does not provide adequate nutrition.
Question 8 of 9
A child is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. What food items would the nurse inform the parents are common allergens?
Correct Answer: C
Rationale: The correct answer is C: Eggs and wheat. This is because eggs and wheat are common food allergens in children. Eggs contain proteins that can trigger allergic reactions, while wheat contains gluten, a common allergen. Citrus fruits and rice (choice A) are not common allergens. Root vegetables and tomatoes (choice B) are also less likely to cause allergies. Hard cheeses and vegetable oils (choice D) are not commonly associated with food allergies in children. Therefore, informing the parents about eggs and wheat as common allergens is crucial for the child's testing and management of food allergies.
Question 9 of 9
A public health nurse is teaching a health class for the male students at the local high school. The nurse is teaching the boys to perform monthly testicular self-examinations. What point would be appropriate to emphasize?
Correct Answer: A
Rationale: The correct answer is A: Testicular cancer is a highly curable type of cancer. This is the most appropriate point to emphasize because early detection through regular self-examinations can lead to early treatment and a high survival rate. Testicular cancer has a very high cure rate, especially when detected and treated early. Emphasizing this point encourages boys to perform monthly self-exams, leading to early detection and better outcomes. Explanation of other choices: B: Testicular cancer is very difficult to diagnose - This is incorrect because testicular cancer is actually one of the more easily detectable cancers through self-examinations. C: Testicular cancer is the number one cause of cancer deaths in males - This is incorrect as testicular cancer is not the leading cause of cancer deaths in males. D: Testicular cancer is more common in older men - This is incorrect as testicular cancer is more common in younger men, typically between the ages of 15 and 44.