ATI RN
foundation of nursing questions and answers Questions
Question 1 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 2 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 3 of 9
A patient with genital herpes is having an acute exacerbation. What medication would the nurse expect to be ordered to suppress the symptoms and shorten the course of the infection?
Correct Answer: D
Rationale: The correct answer is D: Acyclovir (Zovirax). Acyclovir is an antiviral medication specifically used to treat herpes infections, including genital herpes. It works by inhibiting the replication of the herpes virus, thereby suppressing symptoms and shortening the course of the infection. Clotrimazole (A) is an antifungal medication used to treat yeast infections, not effective against viral infections like herpes. Metronidazole (B) is an antibiotic used to treat bacterial infections, not effective against viruses. Podophyllin (C) is a topical treatment for genital warts caused by the human papillomavirus (HPV), not effective for herpes. Therefore, the correct choice is Acyclovir (D) for treating genital herpes exacerbation.
Question 4 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 5 of 9
A patient with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the patient?
Correct Answer: A
Rationale: The correct answer is A: Sit or stand in front of the patient when speaking. This choice is correct because it allows the patient with otosclerosis to directly see the nurse's face and lip movements, aiding in lip-reading and understanding speech. Sitting or standing in front of the patient also ensures better eye contact and reduces background noise interference. Choice B is incorrect because exaggerated lip and mouth movements may distort speech and make it harder for the patient to understand. Choice C is incorrect because standing in front of a light or window can create glare and make it difficult for the patient to see the nurse's face clearly. Choice D is incorrect because saying the patient's name loudly before starting to talk does not directly address the communication needs of a patient with otosclerosis.
Question 6 of 9
A woman scheduled for a simple mastectomy in one week is having her preoperative education provided by the clinic nurse. What educational intervention will be of primary importance to prevent hemorrhage in the postoperative period?
Correct Answer: C
Rationale: The correct answer is C: Stop taking aspirin. Aspirin is a blood thinner that can increase the risk of bleeding during and after surgery. By stopping aspirin before surgery, the woman's blood clotting ability will improve, reducing the risk of hemorrhage. A: Limiting intake of green leafy vegetables is not directly related to preventing hemorrhage in the postoperative period. B: Increasing water intake is important for overall health, but it does not specifically address the risk of hemorrhage related to aspirin use. D: Having nothing by mouth for 6 hours before surgery is important for preventing aspiration during anesthesia, but it does not directly address the risk of hemorrhage related to aspirin use.
Question 7 of 9
A nurse is pouching an ostomy on a patient withan ileostomy. Which action by the nurse ismostappropriate?
Correct Answer: B
Rationale: The correct answer is B, emptying the pouch if it is more than one-third to one-half full. This action is appropriate to prevent leakage and skin irritation. When the pouch becomes too full, it can put pressure on the seal, leading to potential leaks. Emptying the pouch at one-third to one-half fullness helps maintain a secure seal and prevents skin breakdown. Choice A is incorrect because changing the skin barrier portion of the ostomy pouch daily is unnecessary and can lead to skin irritation and breakdown. Choice C is incorrect because cleansing the skin around the stoma with soap and water excessively can strip the skin of its natural oils and cause irritation. Choice D is incorrect because leaving a 1/2-inch space around the stoma when measuring for the barrier device may result in an improper fit, leading to leakage and skin issues.
Question 8 of 9
The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patients tumor, the nurse should implement measures to prevent what complication?
Correct Answer: A
Rationale: The correct answer is A: Falls. A cerebellar tumor can affect coordination and balance, leading to an increased risk of falls. Measures to prevent falls include maintaining a clutter-free environment, using assistive devices, and providing supervision. Choice B (Audio hallucinations) is incorrect as cerebellar tumors typically do not cause auditory hallucinations. Choice C (Respiratory depression) is incorrect as cerebellar tumors do not directly affect the respiratory system. Choice D (Labile BP) is incorrect as cerebellar tumors are not typically associated with blood pressure fluctuations.
Question 9 of 9
The nurse is providing home care for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which dietary intervention will the nurse add to the care plan?
Correct Answer: A
Rationale: The correct answer is A because providing small, frequent nutrient-dense meals helps maximize kilocalories, which is important for patients with AIDS who may have difficulty maintaining weight due to their compromised immune system. This approach ensures the patient receives essential nutrients and energy to support their immune function. Choice B is incorrect as there is no evidence to suggest that hot meals are more easily tolerated by AIDS patients. Choice C is incorrect because limiting liquids can lead to dehydration, which is especially detrimental for individuals with weakened immune systems. Choice D is incorrect as encouraging the intake of fatty foods may not necessarily provide the necessary nutrients and energy required for immune support in AIDS patients.