ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?
Correct Answer: A
Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely
Question 2 of 9
The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?
Correct Answer: A
Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely
Question 3 of 9
A patient has experienced occasional urinary incontinence in the weeks since his prostatectomy. In order to promote continence, the nurse should encourage which of the following?
Correct Answer: A
Rationale: The correct answer is A: Pelvic floor exercises. Pelvic floor exercises help strengthen the muscles that control urination, promoting continence. These exercises can improve bladder control and reduce urinary incontinence post-prostatectomy. Intermittent urinary catheterization (B) may lead to increased risk of infection. Reduced physical activity (C) can weaken pelvic floor muscles, worsening incontinence. Active range of motion exercises (D) do not directly address urinary incontinence.
Question 4 of 9
A nurse is developing a plan to reduce data entryerrors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: Implement an automatic sign-off. This guideline helps reduce data entry errors by ensuring that all entries are completed and saved before exiting the system, thus maintaining confidentiality. Bypassing the firewall (A) would compromise data security. Creating a password with just letters (C) may not be secure enough. Using a programmed speed-dial key when faxing (D) is unrelated to reducing data entry errors or maintaining confidentiality.
Question 5 of 9
An abortion when the fetus dies but is retained in the uterus is called
Correct Answer: B
Rationale: The correct answer is B: missed. In a missed abortion, the fetus dies but is not immediately expelled from the uterus. This term specifically describes the situation where the fetus is retained in the uterus. Choice A (inevitable) refers to a situation where abortion is certain to occur, choice C (incomplete) refers to partial expulsion of the fetus, and choice D (threatened) refers to a situation where the woman has vaginal bleeding, but the fetus is still viable. Therefore, the term "missed" accurately describes the scenario where the fetus dies but remains in the uterus.
Question 6 of 9
A patient who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The labor and birth nurse performs the NfollRowiIng aGssesBsm.eCntsM. The vaginal exam is deferred until the U S N T O physician is in attendance. The patient is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The patient is then transferred to the antepartum unit for continued observation. Several hours later, the patient complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The patient is placed on the EFM and no fetal heart tones are observed. What does the nurse suspect is occurring?
Correct Answer: D
Rationale: The correct answer is D: Hidden placental abruption. In this scenario, the patient had PROM and is now presenting with decreased fetal movement and absence of fetal heart tones after a fundal height increase. These signs suggest a hidden placental abruption, where the placenta has partially detached, leading to fetal distress and potential fetal demise. The absence of contractions rules out active labor (B) as the cause. Placental previa (A) would typically present with painless vaginal bleeding, which is not described in the scenario. Placental abruption (C) usually presents with painful vaginal bleeding, which is also not mentioned. Therefore, the most likely explanation for the symptoms described is a hidden placental abruption.
Question 7 of 9
Massage around the feces and work down to remove.
Correct Answer: A
Rationale: The correct order for the massage is to start around the feces (4), then work downwards (1), followed by moving towards the sides (5), then back to the top (2), continuing to the sides again (3), and finally finishing at the top (6). This sequence ensures a thorough and effective massage process. Other choices have different orders that do not follow the logical flow of massaging around the feces and working down as specified in the question.
Question 8 of 9
A nurse is caring for a male patient with urinaryretention. Which action should the nurse takefirst?
Correct Answer: C
Rationale: The correct answer is C: Assist to a standing position. This action helps utilize gravity to aid in emptying the bladder and may help the patient void without the need for invasive measures like catheterization or medications. It is a non-invasive and natural approach to promote urination. Limiting fluid intake (A) could worsen the situation by concentrating urine and worsening retention. Inserting a urinary catheter (B) should be considered only if other measures fail. Asking for a diuretic medication (D) does not address the immediate need for bladder emptying and may not be necessary if the patient can void naturally.
Question 9 of 9
A patient is using laxatives three times dailyto lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient?
Correct Answer: A
Rationale: The correct answer is A. Long-term laxative use can lead to the bowel becoming less responsive to stimuli, resulting in constipation. This is due to the body becoming dependent on laxatives to stimulate bowel movements. Choice B is incorrect as laxatives typically do not cause trauma or scarring to the intestinal lining. Choice C is incorrect because while emollient laxatives can be helpful for constipation, long-term use is not recommended due to potential side effects. Choice D is incorrect because laxatives do not directly cause malnourishment or prevent waste production.