ATI RN
foundation of nursing questions Questions
Question 1 of 5
What should the nurse recognize as evidence that the patient is recovering from preeclampsia?
Correct Answer: C
Rationale: Step 1: Increased urine output indicates improved kidney function, a key indicator of recovery from preeclampsia. Step 2: Adequate urine output helps regulate blood pressure and reduce swelling. Step 3: Consistent urine output >100 mL/hour signifies the kidneys are functioning properly. Step 4: Therefore, C is the correct answer as it directly reflects recovery progress from preeclampsia. Summary: A, B, and D are incorrect as they do not directly correlate with kidney function or recovery from preeclampsia.
Question 2 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 3 of 5
The nurse is reviewing the instructions given to a patient at 24 weeks’ gestation for a glucose challenge test (GCT). The nurse determines that the patient understands the teaching when she makes which statement?
Correct Answer: C
Rationale: The correct answer is C: “I will have blood drawn at 1 hour after I drink the glucose solution.” This statement demonstrates understanding of the GCT procedure. The glucose challenge test involves drinking a sugary solution, followed by blood drawn 1 hour later to measure blood glucose levels. This timing is crucial for assessing the body's ability to metabolize glucose, which helps in diagnosing gestational diabetes. Explanation of why the other choices are incorrect: A: “I have to fast the night before the test.” - This is incorrect as fasting is not required for the GCT. B: “I will drink a sugary solution containing 100 g of glucose.” - This is incorrect as the GCT typically involves drinking a solution with a standardized amount of glucose, usually 50 g, not 100 g. D: “I should keep track of my baby’s movements between now and the test.” - This is unrelated to the GCT procedure and does not demonstrate understanding of the
Question 4 of 5
A nurse is aware of the need to assess patients risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis?
Correct Answer: C
Rationale: The correct answer is C: Computed tomography with contrast solution. This procedure involves the use of contrast agents that can trigger anaphylaxis due to the patient's allergic reaction to the contrast solution. Contrast solutions contain substances like iodine, which can cause severe allergic reactions in some individuals. Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and requires immediate intervention. Assessing the risk for anaphylaxis during this procedure is crucial to prevent any potential harm to the patient. Incorrect choices: A: Administration of the measles-mumps-rubella (MMR) vaccine - While allergic reactions can occur with vaccines, the risk of anaphylaxis with MMR vaccine is lower compared to the contrast solution used in CT scans. B: Rapid administration of intravenous fluids - Rapid IV fluid administration can cause fluid overload or electrolyte imbalances, but it is not typically associated with triggering anaphylaxis. D: Administration of nebulized bronchodil
Question 5 of 5
The advanced practice nurse is attempting to examine the patients ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patients ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure?
Correct Answer: A
Rationale: Correct Answer: A. Maintain the irrigation fluid at a warm temperature. Rationale: 1. Warm fluid helps prevent vertigo and nausea by minimizing stimulation of the vestibular system. 2. Cold fluid can cause dizziness and nausea due to the temperature effect on the inner ear. 3. Warm fluid promotes patient comfort and relaxation during the procedure. 4. Cold fluid can lead to vasoconstriction, potentially exacerbating ear discomfort. Summary of other choices: B. Instilling short, sharp bursts of fluid can be uncomfortable and increase the risk of vertigo and nausea. C. Following with a curette may not be necessary if the irrigation effectively removes the impacted cerumen. D. Having the patient stand can increase the risk of falling or losing balance due to potential dizziness from the procedure.
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