ATI RN
foundations of nursing practice questions Questions
Question 1 of 5
A patient who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The labor and birth nurse performs the NfollRowiIng aGssesBsm.eCntsM. The vaginal exam is deferred until the U S N T O physician is in attendance. The patient is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The patient is then transferred to the antepartum unit for continued observation. Several hours later, the patient complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The patient is placed on the EFM and no fetal heart tones are observed. What does the nurse suspect is occurring?
Correct Answer: D
Rationale: The correct answer is D: Hidden placental abruption. In this scenario, the patient had PROM and is now presenting with decreased fetal movement and absence of fetal heart tones after a fundal height increase. These signs suggest a hidden placental abruption, where the placenta has partially detached, leading to fetal distress and potential fetal demise. The absence of contractions rules out active labor (B) as the cause. Placental previa (A) would typically present with painless vaginal bleeding, which is not described in the scenario. Placental abruption (C) usually presents with painful vaginal bleeding, which is also not mentioned. Therefore, the most likely explanation for the symptoms described is a hidden placental abruption.
Question 2 of 5
A patient has been diagnosed with endometriosis. When planning this patients care, the nurse should prioritize what nursing diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Acute pain related to misplaced endometrial tissue. This nursing diagnosis should be prioritized because endometriosis commonly presents with severe pelvic pain. Managing pain is crucial for the patient's comfort and quality of life. Anxiety (choice A) is not the priority as pain management takes precedence. Ineffective tissue perfusion (choice C) is not a priority unless the patient is actively hemorrhaging. Excess fluid volume (choice D) is not typically associated with endometriosis. Prioritizing pain management will address the immediate and most distressing symptom for the patient.
Question 3 of 5
The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction?
Correct Answer: A
Rationale: The correct answer is A: Anaphylactic reaction after a bee sting. Type I hypersensitivity reactions involve an immediate response triggered by exposure to an allergen, leading to the release of histamine and other inflammatory mediators. In this case, a bee sting would introduce an allergen, causing a rapid and severe systemic reaction, known as anaphylaxis. B: Skin reaction resulting from adhesive tape is an example of a Type IV hypersensitivity reaction, mediated by T cells, not IgE antibodies as in Type I reactions. C: Myasthenia gravis is an autoimmune disorder involving antibodies attacking acetylcholine receptors, not a Type I hypersensitivity reaction. D: Rheumatoid arthritis is an autoimmune disorder involving immune complexes and inflammatory responses, not a Type I hypersensitivity reaction.
Question 4 of 5
The nurse is assessing a patient for nutritional status. Which action will the nurse take?
Correct Answer: D
Rationale: The correct answer is D, combining multiple objective measures with subjective measures. This approach provides a comprehensive assessment of the patient's nutritional status by incorporating both quantitative data (objective measures) such as weight, BMI, and laboratory values, as well as qualitative information (subjective measures) like dietary history and appetite changes. By combining these measures, the nurse can obtain a more holistic view of the patient's nutritional status, allowing for better identification of nutritional deficiencies or excesses. This method enhances the accuracy and reliability of the assessment compared to relying solely on one type of measure. Choice A is incorrect because nutritional assessment is crucial even in the presence of chronic disease to address potential malnutrition risks. Choice B is incorrect as the Mini Nutritional Assessment is not intended for pediatric patients but for adults. Choice C is incorrect as using a single tool may not capture the full complexity of the patient's nutritional status.
Question 5 of 5
A nurse is providing care to a patient with anindwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)?
Correct Answer: A
Rationale: The correct answer is A: Drapes the urinary drainage tubing with no dependent loops. This practice helps prevent CAUTI by ensuring that urine does not flow back into the bladder, reducing the risk of infection. Dependent loops can lead to stagnant urine, providing a breeding ground for bacteria. Choice B is incorrect because washing the drainage tube towards the meatus can introduce bacteria into the urinary tract, increasing the risk of infection. Choice C is incorrect because placing the drainage bag on the floor can introduce contaminants from the floor into the system. Choice D is incorrect because allowing the spigot to touch the receptacle can lead to contamination and increase the risk of infection.
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