ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
The patient is having lower abdominal surgeryand the nurse inserts an indwelling catheter. What is the rationale for the nurse’s action?
Correct Answer: C
Rationale: The correct answer is C because anesthetics used during surgery can decrease bladder contractility, leading to urinary retention. By inserting an indwelling catheter, the nurse ensures proper drainage of urine and prevents bladder distention. This helps to maintain the patient's comfort and prevent complications such as urinary retention and potential bladder injury. Choice A is incorrect because inserting a catheter is not primarily to prevent uncontrollable voiding during surgery. Choice B is incorrect as local trauma does not promote excessive urine incontinence necessitating catheterization. Choice D is incorrect because the primary purpose of catheter insertion is not to prevent interruption of the procedure by bathroom breaks.
Question 2 of 9
The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first medication, how long should the nurse wait before instilling the patients second medication into the same eye?
Correct Answer: C
Rationale: The correct answer is C: 3 minutes. After administering the first eye drop, waiting for 3 minutes before instilling the second medication allows for proper absorption and effectiveness of each medication. This interval prevents dilution or interaction between the medications. Option A (30 seconds) is too short, not allowing sufficient time for absorption. Option B (1 minute) is also inadequate for proper absorption. Option D (5 minutes) is unnecessarily long and may lead to patient discomfort or inconvenience.
Question 3 of 9
A nurse and a patient work on strategies to reduceweight. Which phase of the helping relationship is the nurse in with this patient?
Correct Answer: C
Rationale: The correct answer is C: Working. In the working phase, the nurse and patient actively collaborate on achieving goals, such as weight reduction strategies. The nurse assesses, plans, and implements interventions with the patient. During this phase, the focus is on building trust, exploring feelings, and identifying and addressing issues. The other choices are incorrect because in the preinteraction phase (A), there is no direct interaction yet, in the orientation phase (B), the relationship is being established, and in the termination phase (D), the relationship is coming to an end. Thus, the nurse being engaged in weight reduction strategies with the patient indicates that they are in the working phase of the helping relationship.
Question 4 of 9
Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?
Correct Answer: C
Rationale: The correct answer is C: Fundal height measurement of 18 cm. This finding suggests a hydatidiform mole because it is larger than expected for a 10-week pregnancy due to excessive trophoblastic proliferation. A: Blood pressure is within normal range. B: Nausea is common in early pregnancy and not specific to a mole. D: History of bright red spotting is more indicative of a miscarriage or other complications, not necessarily a mole.
Question 5 of 9
A nurse is inserting an indwelling urinary catheterfor a male patient. Which action will the nurse take?
Correct Answer: D
Rationale: The correct answer is D because cleansing the meatus with circular strokes starting at the meatus and moving outward helps prevent the introduction of bacteria into the urethra. This technique minimizes the risk of urinary tract infections. Holding the shaft at a 60-degree angle (A) or with the dominant hand (B) is not necessary for catheter insertion. Cleansing the meatus 3 times with the same cotton ball (C) can introduce more bacteria and is not recommended.
Question 6 of 9
A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?
Correct Answer: C
Rationale: The correct choice is C because if no urine is obtained, it indicates that the catheter is not in the urethra. The nurse should remove the catheter, wipe with alcohol to maintain cleanliness, and reinsert after lubrication to ensure proper placement in the urethra. This step-by-step approach allows for a more accurate catheter insertion and prevents potential complications. Choice A is incorrect as discarding the catheter and starting over without addressing the issue does not solve the problem. Choice B is incorrect as filling the balloon with sterile water is not relevant to the situation of catheter misplacement. Choice D is incorrect as leaving the catheter in the vagina can lead to infection and is not a recommended practice.
Question 7 of 9
Which nursing actions will the nurse implementwhen collecting a urine specimen from a patient? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: Labeling all specimens with date, time, and initials. This is important for proper identification and tracking of the specimen. - Choice A is incorrect because urine cultures typically take longer than 12 hours to grow. - Choice C is incorrect as privacy is important but not a specific action related to urine specimen collection. - Choice D is incorrect as wearing gown, gloves, and mask may not be necessary for routine urine specimen collection, unless there are specific precautions needed.
Question 8 of 9
A patient who was diagnosed with Parkinsons disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced significant symptom relief. The nurse should be aware of what implication of the patients medication regimen?
Correct Answer: A
Rationale: The correct answer is A. The patient is in a honeymoon period when adverse effects of levodopa-carbidopa are not yet evident. This is because the initial response to levodopa-carbidopa in Parkinson's disease can be very positive, leading to significant symptom relief. However, over time, as the disease progresses and the body adjusts to the medication, adverse effects such as dyskinesias may become more prominent. Choice B is incorrect because the benefits of levodopa-carbidopa can be seen relatively soon after initiation of treatment and do not necessarily take 6 to 9 months to peak. Choice C is incorrect as the temporary improvement is likely related to the medication, given the significant symptom relief experienced. Choice D is incorrect because while benefits may diminish over time, it is not necessarily after 1 or 2 years of treatment, and some patients may continue to benefit from the medication long-term.
Question 9 of 9
A clinic nurse is providing patient education prior to a patients scheduled palliative radiotherapy to her spine. At the completion of the patient teaching, the patient continues to ask the same questions that the nurse has already addressed. What is the plausible conclusion that the nurse should draw from this?
Correct Answer: D
Rationale: The correct answer is D. The plausible conclusion the nurse should draw is that the patient has not achieved the desired learning outcomes. 1. The patient's repeated questions indicate a lack of understanding despite the nurse's teaching efforts. 2. This suggests that the patient has not grasped the information provided. 3. It does not necessarily mean the patient is not listening effectively, noncompliant, or has low intelligence. 4. The focus should be on reassessing the teaching methods and providing additional support to help the patient achieve the desired learning outcomes.