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 patient who is receiving care for osteosarcoma has been experiencing severe pain since being diagnosed. As a result, the patient has been receiving analgesics on both a scheduled and PRN basis. For the past several hours, however, the patients level of consciousness has declined and she is now unresponsive. How should the patients pain control regimen be affected?
Correct Answer: C
Rationale: The correct answer is C. When a patient's level of consciousness declines and becomes unresponsive, it may indicate a potential overdose of analgesics. To ensure patient safety, IV analgesics should be withheld and replaced with transdermal analgesics, which provide a more controlled and gradual release of medication. This switch helps prevent further overdose and adverse effects. Continuing the current pain control regimen (Choice A) may worsen the situation. Placing the pain control regimen on hold (Choice B) may lead to inadequate pain management. Reducing analgesic dosages (Choice D) may not be sufficient in addressing the overdose issue.
Question 3 of 9
A nurse is assessing a patient’s ethnohistory.Which question should the nurse ask?
Correct Answer: B
Rationale: The correct answer is B because it directly addresses the patient's ethnohistory by asking about the differences in their life here compared to back home. This question helps the nurse understand the patient's cultural background, beliefs, and practices. Option A focuses solely on language, which is not sufficient to understand ethnohistory. Option C inquires about caregivers during sickness, which is important but does not specifically relate to ethnohistory. Option D compares treatment approaches, which is relevant but doesn't explore the broader cultural context as effectively as option B.
Question 4 of 9
A nurse providing prenatal care to a pregnant woman is addressing measures to reduce her postpartum risk of cystocele, rectocele, and uterine prolapse. What action should the nurse recommend?
Correct Answer: D
Rationale: The correct answer is D, performance of pelvic muscle exercises. Pelvic muscle exercises, also known as Kegel exercises, help strengthen the pelvic floor muscles which support the bladder, uterus, and bowel. By strengthening these muscles, the risk of developing cystocele, rectocele, and uterine prolapse postpartum is reduced. It is a proactive approach to prevent these conditions. Choice A, maintenance of good perineal hygiene, is important for preventing infections but does not specifically address the risk of pelvic organ prolapse. Choice B, prevention of constipation, is also important but does not directly target the muscle weakness that contributes to prolapse. Choice C, increased fluid intake for 2 weeks postpartum, is not as effective in preventing prolapse as pelvic muscle exercises. In summary, pelvic muscle exercises are the most appropriate recommendation as they directly address strengthening the muscles that support the pelvic organs, reducing the risk of prolapse postpartum.
Question 5 of 9
The nurse is leading a workshop on sexual health for men. The nurse should teach participants that organic causes of erectile dysfunction include what? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Diabetes. Erectile dysfunction can be caused by organic factors, such as diabetes, which affects blood flow and nerve function. Diabetes can lead to damage of blood vessels and nerves, impacting the ability to achieve and maintain an erection. Testosterone deficiency (choice B) can also contribute to erectile dysfunction, but it is not an organic cause. Anxiety (choice C) and depression (choice D) are psychological factors that can lead to erectile dysfunction, not organic causes. Parkinsonism (choice E) can affect sexual function, but it is not a common organic cause of erectile dysfunction.
Question 6 of 9
A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL.
Correct Answer: C
Rationale: The correct answer is C (900 mL) because the weight of 900 g corresponds to a blood loss of the same amount in milliliters. Blood density is close to that of water, so 1 g ≈ 1 mL. Therefore, a blood-soaked peripad weighing 900 g indicates a blood loss of 900 mL. Choice A (1800 mL) is incorrect as it doubles the weight instead of converting it to milliliters. Choice B (450 mL) is incorrect as it halves the weight. Choice D (90 mL) is incorrect as it divides the weight by 10, which is too small for the blood loss indicated.
Question 7 of 9
A nurse is charting on a patient’s record. Whichaction will the nurse take that is accurate legally?
Correct Answer: A
Rationale: The correct answer is A: Charts legibly. This is accurate legally because clear and legible documentation is crucial for accurately conveying patient information, ensuring continuity of care, and meeting legal standards. Illegible handwriting can lead to errors in patient care and legal issues. Choice B is incorrect as labeling a patient as "belligerent" without evidence can be perceived as unprofessional and potentially harmful to the patient. Choice C is incorrect as writing an entry for another nurse can lead to inaccurate documentation and legal consequences. Choice D is incorrect because using correction fluid can raise suspicion of tampering with records and compromise the integrity of the documentation.
Question 8 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 9 of 9
A patient on the medical unit is dying and the nurse has determined that the familys psychosocial needs during the dying process need to be addressed. What is a cause of many patient care dilemmas at the end of life?
Correct Answer: B
Rationale: The correct answer is B: Denial of imminent death on the part of the family or the patient. This is a common cause of patient care dilemmas at the end of life because denial can lead to unrealistic expectations, difficulty in making important decisions, and inadequate planning for end-of-life care. This can result in unnecessary suffering for the patient and added stress for the family. Incorrect choices: A: Poor communication between the family and the care team can contribute to challenges in providing appropriate care but may not be the primary cause of patient care dilemmas at the end of life. C: Limited visitation opportunities for friends and family, while important for psychosocial support, may not directly cause patient care dilemmas. D: Conflict between family members can complicate decision-making processes, but it is not necessarily a primary cause of patient care dilemmas at the end of life.