ATI RN
foundations of nursing test bank Questions
Question 1 of 5
A patient who has AIDS has been admitted for the treatment of Kaposis sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS?
Correct Answer: B
Rationale: The correct answer is
B) Impaired Skin Integrity Related to Kaposis Sarcoma. Kaposis sarcoma can cause skin lesions that may lead to impaired skin integrity due to tissue breakdown. The nurse should prioritize interventions to prevent infection and promote wound healing.
Choice A is incorrect because Disuse Syndrome is not directly related to Kaposis Sarcoma.
Choice C, Diarrhea, is not a common complication of Kaposis Sarcoma.
Choice D, Impaired Swallowing, is not typically associated with Kaposis Sarcoma.
Question 2 of 5
An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?
Correct Answer: D
Rationale:
Correct
Answer: D - Avoid rubbing or scratching the affected area
Rationale:
1. Rubbing or scratching can further damage the already compromised skin integrity.
2. By avoiding rubbing or scratching, the patient reduces the risk of infection and delayed healing.
3. This intervention promotes skin healing and prevents worsening of the condition.
Summary:
A: Applying ice pack or heating pad may provide temporary relief but does not address the root cause of impaired skin integrity.
B: Avoiding skin contact with water is not necessary and may not directly improve skin integrity.
C: Phototherapy is not indicated for erythematous reactions to radiation therapy and may not address the issue.
Question 3 of 5
Which maternal condition always necessitates delivery by cesarean birth?
Correct Answer: B
Rationale: The correct answer is B:
Total placenta previa. In this condition, the placenta completely covers the cervix, posing a risk of severe bleeding during vaginal delivery. Cesarean birth is necessary to avoid potential life-threatening complications for both the mother and the baby.
Partial abruptio placentae (choice
A) involves premature separation of the placenta, but it doesn't always require a cesarean birth. Ectopic pregnancy (choice
C) occurs when the fertilized egg implants outside the uterus, typically requiring surgical intervention but not always a cesarean birth. Eclampsia (choice
D) is a serious condition characterized by high blood pressure and seizures, but it doesn't always necessitate cesarean birth unless there are other complications that require it.
Question 4 of 5
A patient with a genital herpes exacerbation has a nursing diagnosis of acute pain related to the genital lesions. What nursing intervention best addresses this diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Keep the lesions clean and dry. This intervention helps prevent infection and promotes healing. Cleaning the lesions reduces the risk of secondary infections and discomfort. Keeping the area dry can also help alleviate pain and discomfort associated with moisture. Covering with a topical antibiotic (
A) may not address pain directly and could potentially irritate the lesions. Applying a topical NSAID (
C) may provide some pain relief but does not address the primary need to keep the lesions clean and dry. Remaining on bed rest (
D) is not necessary for managing acute pain related to genital lesions.
Question 5 of 5
A nurse is preparing to lavage a patient in theemergency department for an overdose. Which tube should the nurse obtain?
Correct Answer: A
Rationale: The correct answer is A: Ewald tube. This tube is used for gastric lavage due to its large diameter and open end which allows for effective suction of gastric contents. The Ewald tube is specifically designed for gastric lavage and is ideal for removing toxins from the stomach.
Summary of why the other choices are incorrect:
B: Dobhoff tube is a small-bore feeding tube, not suitable for gastric lavage.
C: Miller-Abbott tube is used for intestinal decompression, not gastric lavage.
D: Sengstaken-Blakemore tube is used for esophageal varices, not gastric lavage.