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
A patient, who delivered her third child yesterday, has just learned that her two school-age children have contracted chickenpox. What should the nurse tell her?
Correct Answer: D
Rationale: The correct answer is D: She must make arrangements to stay somewhere other than her home until the children are no longer contagious. 1. The patient's newborn is at risk of contracting chickenpox from the infected children. 2. Chickenpox can be severe in newborns due to their immature immune systems. 3. It is crucial to protect the newborn by ensuring they are not exposed to the virus. 4. Staying elsewhere until the children are no longer contagious will prevent transmission to the newborn. Incorrect choices: A: Acyclovir is not recommended for prophylactic treatment in this situation. B: Immunity is not automatically transferred from the mother to the baby for chickenpox. C: Allowing the infected children to visit with precautions is not sufficient to protect the newborn.
Question 3 of 9
A nurse is preparing to document a patient whohas chest pain. Which information is critical for the nurse to include?
Correct Answer: D
Rationale: The correct answer is D because documenting the patient's pain intensity using a pain scale (8 out of 10) is crucial for assessing the severity of the chest pain. This information helps in determining the appropriate intervention and monitoring the effectiveness of treatment. Choice A is irrelevant as it does not provide any useful information about the patient's condition. Choice B is important for neurological assessment but not specifically related to chest pain. Choice C is not as critical as knowing the current pain level.
Question 4 of 9
The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the patients plan of care?
Correct Answer: C
Rationale: Correct Answer: C Rationale: 1. Exostoses are bony growths in the external auditory canal. 2. These growths can cause narrowing and obstruction of the canal, affecting hearing. 3. Collaborating with the pharmacist to assess for ototoxic medications is crucial to prevent further hearing impairment. 4. Performing Rinne and Weber tests (choice A) and arranging audiometry testing (choice B) are not directly related to exostoses. 5. Ignoring exostoses (choice D) can lead to worsening hearing loss and potential complications.
Question 5 of 9
A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient?
Correct Answer: D
Rationale: The correct answer is D: Obtain a stool culture to identify possible pathogens. This is the most appropriate nursing intervention because chronic diarrhea in a patient with AIDS can be caused by various pathogens such as parasites, bacteria, or viruses. By obtaining a stool culture, the healthcare team can identify the specific pathogen responsible for the diarrhea and initiate targeted treatment. A: Positioning the patient in the high Fowler's position is not directly related to addressing the underlying cause of chronic diarrhea in this patient. B: Temporarily eliminating animal protein from the patient's diet may not be necessary or effective in treating chronic diarrhea without knowing the specific cause identified through stool culture. C: Making sure the patient eats raw fruit is not recommended as raw fruits can sometimes worsen diarrhea due to their high fiber content and potential for carrying pathogens. In summary, obtaining a stool culture is the most appropriate intervention as it helps identify the specific pathogen causing the diarrhea, while the other options do not directly address the underlying cause.
Question 6 of 9
Before giving the patient an intermittent gastric tube feeding, what should the nurse do?
Correct Answer: B
Rationale: The correct answer is B because injecting air into the stomach via the tube and auscultating helps confirm the tube placement in the stomach before administering the feeding. This step ensures the safety of the patient by preventing accidental lung feeding. Choice A is incorrect because securing the tube with a safety pin to the gown is not a standard practice and can lead to complications. Choice C is incorrect because the temperature of the feeding does not affect the tube placement or safety. Choice D is incorrect because checking the pH level is not a reliable method for verifying tube placement.
Question 7 of 9
Which finding would indicate concealed hemorrhage in abruptio placentae?
Correct Answer: B
Rationale: The correct answer is B: Hard boardlike abdomen. In abruptio placentae, concealed hemorrhage can lead to blood accumulating behind the placenta, causing the uterus to become tense and rigid, resulting in a hard boardlike abdomen. This finding indicates significant internal bleeding and requires immediate medical attention. Rationale: A: Bradycardia is a slow heart rate and is not typically associated with concealed hemorrhage in abruptio placentae. C: Decrease in fundal height may indicate intrauterine growth restriction, not specifically concealed hemorrhage. D: Decrease in abdominal pain is not a typical indicator of concealed hemorrhage; in fact, pain may increase due to the increased pressure in the uterus from the bleeding.
Question 8 of 9
A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action?
Correct Answer: A
Rationale: The correct answer is A because instilling the medication in the conjunctival sac allows for direct absorption into the eye tissues. This method ensures that the medication reaches the target area for treating glaucoma effectively. Maintaining a supine position (choice B) or keeping the eyes closed (choice C) after administration does not enhance absorption and may lead to wasted medication. Applying the medication to the sclera (choice D) is incorrect as it does not target the specific area needed for treating glaucoma.
Question 9 of 9
A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having trouble breathing. What should the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Anaphylaxis due to a latex allergy. Anaphylaxis is a severe allergic reaction that can be triggered by exposure to latex products such as gloves in the operating room. The symptoms of swelling of the eyes and difficulty breathing are classic signs of anaphylaxis. Rationale: 1. Swelling of the eyes and difficulty breathing are hallmark symptoms of anaphylaxis. 2. Latex is a common allergen that can cause severe allergic reactions like anaphylaxis. 3. The student's symptoms are occurring shortly after entering the operating room, suggesting an acute allergic reaction. 4. The other choices (A, B, D) do not align with the symptoms presented and are less likely in this scenario.