ATI RN
foundation of nursing questions Questions
Question 1 of 9
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 9
The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient?
Correct Answer: A
Rationale: The correct answer is A because providing instructions in simple, clear terms is crucial when communicating with a blind patient. This method allows the patient to understand information effectively without visual cues. Choice B is incorrect because a firm, loud voice may startle the patient. Choice C is incorrect as touching a patient without consent may be inappropriate. Choice D is incorrect because stating name and role without context may confuse the patient.
Question 3 of 9
A nurse is planning the postoperative care of a patient who is scheduled for radical prostatectomy. What intraoperative position will place the patient at particular risk for the development of deep vein thrombosis postoperatively?
Correct Answer: D
Rationale: The correct answer is D: Lithotomy position. In lithotomy position, the patient's legs are elevated and positioned higher than the heart, which can lead to venous stasis and increase the risk of deep vein thrombosis (DVT). This position compresses the femoral veins, hindering blood flow and predisposing the patient to DVT formation. Summary: A: Fowlers position - Not typically associated with increased DVT risk. B: Prone position - Not typically associated with increased DVT risk. C: Supine position - Generally considered a safe position regarding DVT risk.
Question 4 of 9
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.
Question 5 of 9
An oncology patient has just returned from the postanesthesia care unit after an open hemicolectomy. This patients plan of nursing care should prioritize which of the following?
Correct Answer: C
Rationale: The correct answer is C because assessing the patient's wound for dehiscence every 4 hours is crucial post hemicolectomy to monitor for any signs of wound complications, such as infection or tissue breakdown. This allows for early detection and intervention, promoting optimal wound healing and preventing potential complications. Choice A is incorrect as compartment syndrome is not a common complication after a hemicolectomy, and assessing for it hourly would be excessive and unnecessary. Choice B is incorrect as assessing fine motor skills is not a priority in the immediate postoperative period following a hemicolectomy. Choice D is incorrect as maintaining the patient's head of bed at 45 degrees or more is important for preventing respiratory complications, but it is not the top priority compared to wound assessment for dehiscence in this scenario.
Question 6 of 9
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 7 of 9
When planning discharge teaching with a patient who has undergone a total mastectomy with axillary dissection, the nurse knows to instruct the patient that she should report what sign or symptom to the physician immediately?
Correct Answer: C
Rationale: The correct answer is C: Sudden cessation of output from the drainage device. This is crucial because it can indicate a potential complication like a blocked drain or infection, requiring immediate medical attention to prevent further issues. Other choices like fatigue (A) are common after surgery but not urgent. Temperature elevation (B) may indicate infection but is not as critical as sudden cessation of drainage. Gradual decline in output (D) is expected as the drainage decreases over time, so it doesn't require immediate reporting.
Question 8 of 9
A patient has herpes simplex 2 viral infection (HSV2). The nurse recognizes that which of the following should be included in teaching the patient?
Correct Answer: D
Rationale: The correct answer is D because treatment for HSV2 focuses on relieving symptoms since the virus cannot be cured. Antiviral medications can help manage outbreaks and reduce the frequency and severity of symptoms. Option A is incorrect as HSV2 typically presents as genital herpes, not cold sores on the lips (usually caused by HSV1). Option B is incorrect since antibiotics are ineffective against viruses. Option C is incorrect as HSV2 is most contagious during active outbreaks, making it important to practice safe sex to prevent transmission.
Question 9 of 9
A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?
Correct Answer: D
Rationale: Rationale: Option D is correct because raising the head of the bed promotes a more natural position for defecation, allowing gravity to assist. This position helps align the rectum and anal canal, making it easier for the patient to have a bowel movement. Administering laxatives (Option C) may help, but adjusting the bed position is a non-invasive and more immediate intervention. Withholding pain medication (Option B) could lead to unnecessary discomfort for the patient. Administering a barium enema (Option A) is not indicated for addressing difficulty with defecation.