ATI RN
foundations of nursing test bank Questions
Question 1 of 9
Which findings should the nurse follow up on afterremoval of a catheter from a patient? (Select allthat apply.)
Correct Answer: B
Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection. A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal. C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem. D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.
Question 2 of 9
A nurse is performing a cultural assessment usingthe ETHNIC mnemonic for communication. Which area will the nurse assess for the “H”?
Correct Answer: B
Rationale: The correct answer is B: Healers. In the ETHNIC mnemonic, "H" stands for Healers, where the nurse assesses the individual's traditional healers, healthcare practices, and preferences for seeking healthcare. This is important in understanding the individual's cultural beliefs and practices related to health and treatment. Assessing "Health" (A) may be important, but it does not specifically address traditional healers. "History" (C) focuses on the individual's cultural background rather than healthcare practices. "Homeland" (D) pertains to the individual's place of origin, which is not directly related to healthcare communication.
Question 3 of 9
A patient has tested HIV-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?
Correct Answer: B
Rationale: The correct answer is B because it shows an understanding that being HIV-positive does not guarantee transmission to the baby. The statement acknowledges the possibility of the baby not being affected, which demonstrates awareness of the varying outcomes. Choice A is incorrect as it assumes abortion is the only option. Choice C is incorrect as it makes an extreme and inaccurate claim. Choice D is incorrect as pregnancy does not decrease the chance of developing AIDS.
Question 4 of 9
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
Correct Answer: D
Rationale: The correct answer is D: Hold the condom by the cuff upon withdrawal. This is important because holding the condom by the cuff helps prevent any potential spillage of bodily fluids. During withdrawal, holding the condom by the base prevents it from slipping off and minimizes the risk of exposure to sexually transmitted infections. Explanation of why other choices are incorrect: A: Attaching the condom prior to erection is incorrect as it may lead to breakage or slipping off during intercourse. B: Reusing a condom with the same partner is highly discouraged due to the risk of breakage, reduced effectiveness, and potential exposure to infections. C: Using skin lotion as a lubricant is not recommended as it can degrade the condom material, increasing the risk of breakage.
Question 5 of 9
Which behaviors indicate the student nurse hasa good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Selectall that apply.)
Correct Answer: D
Rationale: Correct Answer: D Rationale: - Giving a change-of-shift report to the oncoming nurse about the patient is an appropriate action that maintains confidentiality by only sharing necessary patient information with authorized healthcare professionals. - A: Writing the patient’s room number and date of birth on a paper for school is a breach of confidentiality as it exposes sensitive patient information to unauthorized individuals. - B: Printing/copying material from the patient’s health record for a graded care plan is also a breach of confidentiality as it involves sharing patient information without proper authorization. - C: Reviewing assigned patient’s record and another unassigned patient’s record is a violation of HIPAA as it involves accessing patient information that is not necessary for the nurse's duties, risking unauthorized disclosure.
Question 6 of 9
In providing prenatal care to a pregnant patient, what does the nurse teach the expectant mother?
Correct Answer: C
Rationale: The correct answer is C because folic acid is crucial in preventing neural tube defects and anemia in the developing fetus. The nurse should teach the expectant mother about the importance of taking folic acid supplements before and during pregnancy. Folic acid is essential for proper cell division and growth, reducing the risk of birth defects. Choice A is incorrect because calcium intake is important throughout pregnancy, not just in the first trimester. Choice B is incorrect as protein intake should be adequate to support maternal and fetal growth, not decreased. Choice D is incorrect as excessive intake of vitamins and minerals can be harmful to the mother and the baby. In summary, the expectant mother should be educated on the importance of folic acid supplementation to prevent birth defects and anemia, while also ensuring a balanced diet with all essential nutrients.
Question 7 of 9
A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
Correct Answer: B
Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction. Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.
Question 8 of 9
The nurse in an extended care facility is planning the daily activities of a patient with postpolio syndrome. The nurse recognizes the patient will best benefit from physical therapy when it is scheduled at what time?
Correct Answer: B
Rationale: The correct answer is B: In the morning. This is because scheduling physical therapy in the morning allows the patient to benefit from increased energy levels and improved muscle strength and function after a night of rest. Morning sessions can also help set a positive tone for the rest of the day. Choice A: Immediately after meals can lead to discomfort and potential complications like indigestion or reflux. Choice C: Before bedtime may be too late in the day when fatigue levels are higher and may disrupt sleep patterns. Choice D: In the early evening may be less effective as fatigue accumulates throughout the day, and the patient may not have the same level of energy and focus as in the morning.
Question 9 of 9
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
Correct Answer: A
Rationale: The correct answer is A: Utilize a pressure-reducing mattress. This intervention is crucial for preventing pressure ulcers in patients at risk for impaired skin integrity, such as those with HIV. By redistributing pressure, a pressure-reducing mattress helps to alleviate pressure on vulnerable areas, reducing the risk of skin breakdown. Limiting physical activity (B) can lead to muscle atrophy and worsen skin integrity. Applying antibiotic ointment (C) may not address the root cause of skin breakdown. Avoiding synthetic fabrics (D) may be helpful in some cases, but it is not as effective as using a pressure-reducing mattress.