ATI RN
foundation of nursing questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A patient requests the nurse’s help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient’s inability to void?
Correct Answer: A
Rationale: The correct answer is A: The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void. Rationale: Anxiety can lead to tension in the abdominal and perineal muscles, inhibiting the ability to relax and urinate. The sympathetic nervous system response to anxiety can cause urinary retention. So, the patient's frustration in voiding in front of the nurse may be due to anxiety hindering muscle relaxation. Summary of other choices: B: The patient not recognizing physiological signals is less likely as the patient requested assistance to void, indicating awareness of the need to urinate. C: The patient being lonely and seeking attention is not relevant to the inability to void in front of the nurse. D: Inadequate fluid intake may contribute to decreased urine output but is not directly related to the inability to void in front of the nurse.
Question 5 of 5
A 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: Obtaining a midstream urine specimen. This task is within the scope of practice for nursing assistive personnel as it involves collecting a specimen, which is a routine and non-invasive procedure. Nursing assistive personnel are trained to perform basic tasks like specimen collection. Choices B, C, and D involve more complex skills and procedures that require specialized training and knowledge, which are typically performed by licensed nurses. Interpreting bladder scan results (B), inserting a straight catheter (C), and irrigating a catheter (D) all require a higher level of expertise and assessment that nursing assistive personnel are not qualified to do.