ATI RN
foundation of nursing questions and answers Questions
Question 1 of 5
A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
Correct Answer: C
Rationale: The correct answer is C: Increase the patient's oral fluid intake. This is because severe diarrhea can lead to dehydration, which can be dangerous for patients with HIV infection. By increasing oral fluid intake, the patient can stay hydrated and prevent further complications. Administering antidiarrheal medications on a scheduled basis (
Choice
A) may provide temporary relief but does not address the underlying issue of dehydration. Encouraging the patient to eat balanced meals (
Choice
B) and increase activity level (
Choice
D) may be important for overall health but do not directly address the immediate concern of dehydration caused by severe diarrhea.
Question 2 of 5
A patient is receiving opioids for pain. Which bowel assessment is a priority?
Correct Answer: B
Rationale: The correct answer is B: Constipation. When a patient is receiving opioids, constipation is a common side effect due to decreased gut motility. It is a priority assessment because untreated constipation can lead to serious complications such as bowel obstruction. Monitoring for constipation allows for early intervention with stool softeners or laxatives to prevent complications.
Incorrect choices:
A: Clostridium difficile - While important to consider in patients on antibiotics, it is not directly related to opioid use.
C: Hemorrhoids - Although opioids can contribute to constipation which may exacerbate hemorrhoids, it is not the priority assessment.
D: Diarrhea - Opioids typically cause constipation, so diarrhea is less likely to be a priority concern in this scenario.
Question 3 of 5
A 23-year-old woman comes to the free clinic stating I think I have a lump in my breast. Do I have cancer? The nurse instructs the patient that a diagnosis of breast cancer is confirmed by what?
Correct Answer: B
Rationale: The correct answer is B: Mammography. Mammography is the gold standard for diagnosing breast cancer as it can detect abnormalities such as lumps or tumors in the breast tissue. It provides detailed images that can help healthcare providers identify suspicious areas that may require further testing or biopsy. Supervised breast self-examination (choice
A) is important for early detection but is not a diagnostic tool. Fine-needle aspiration (choice
C) is a procedure used to obtain a sample of cells for further analysis but is not definitive for diagnosing breast cancer. Chest x-ray (choice
D) is used to evaluate the lungs and heart, not the breast tissue for cancer.
Question 4 of 5
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 5 of 5
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patients plan of care. The presence of what chronic health problem would most likely prompt this diagnosis?
Correct Answer: D
Rationale: The correct answer is D: Hypogammaglobulinemia. This chronic health problem predisposes individuals to latex allergies due to reduced levels of immunoglobulins, increasing susceptibility to allergic reactions. Latex contains proteins that can trigger immune responses in individuals with compromised immune systems.
Choice A: Herpes simplex is a viral infection and does not directly relate to latex allergies.
Choice B: HIV weakens the immune system but is not specifically associated with latex allergies.
Choice C: Spina bifida is a congenital condition affecting the spinal cord and does not directly impact the likelihood of latex allergies.