ATI RN
foundations of nursing test bank Questions
Question 1 of 9
A nurse is checking orders. Which order shouldthe nurse question?
Correct Answer: B
Rationale: The correct answer is B because giving a hypertonic solution enema to a patient with fluid volume excess can worsen the condition by drawing more fluid into the colon. This can lead to further fluid volume overload and electrolyte imbalances. The other choices are incorrect because: A: Normal saline enema is appropriate for constipation. C: Kayexalate enema is used to treat hyperkalemia, not hypokalemia. D: Oil retention enema is indicated for constipation to soften stool.
Question 2 of 9
The nurse is concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is thepriority?
Correct Answer: B
Rationale: The correct answer is B because verifying tube placement before feeding is essential to prevent pulmonary aspiration. If the tube is not correctly positioned in the stomach, there is a risk of feeding going into the lungs. Observing the color of gastric contents (A) may not always indicate correct placement. Adding blue food coloring (C) is unnecessary and could cause confusion. Running the formula over 12 hours (D) does not address the risk of pulmonary aspiration and does not ensure proper tube placement.
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
To decrease glandular cellular activity and prostate size, an 83-year-old patient has been prescribed finasteride (Proscar). When performing patient education with this patient, the nurse should be sure to tell the patient what?
Correct Answer: A
Rationale: Step 1: Finasteride is a medication that works by decreasing glandular cellular activity and reducing prostate size. Step 2: Dietary supplements can interact with finasteride, potentially affecting its effectiveness or causing adverse effects. Step 3: Reporting the planned use of dietary supplements to the physician ensures proper monitoring and adjustment of the treatment plan. Step 4: This communication promotes patient safety and optimal therapeutic outcomes. Therefore, choice A is correct as it emphasizes the importance of informing the physician about dietary supplement use to ensure the efficacy and safety of finasteride. Choices B, C, and D are incorrect as they do not directly relate to the mechanism of action or specific considerations of finasteride therapy.
Question 5 of 9
A woman is being treated for a tumor of the left breast. If the patient and her physician opt for prophylactic treatment, the nurse should prepare the woman for what intervention?
Correct Answer: D
Rationale: The correct answer is D: Bilateral mastectomy. This intervention involves removing both breasts to reduce the risk of developing breast cancer in the future. For a woman with a history of breast cancer in one breast, opting for bilateral mastectomy can significantly decrease the likelihood of cancer recurrence. This proactive approach is often recommended for individuals with a high risk of developing breast cancer. Explanation for why the other choices are incorrect: A: More aggressive chemotherapy - Chemotherapy is typically used to treat existing cancer cells, not as a prophylactic measure to prevent cancer. B: Left mastectomy - This option only removes the affected breast, not addressing the risk of cancer developing in the other breast. C: Radiation therapy - While radiation therapy can be used as part of the treatment for breast cancer, it is not a prophylactic measure to prevent future cancer development in the contralateral breast.
Question 6 of 9
A student nurse is doing clinical hours at an OB/GYN clinic. The student is helping to develop a plan of care for a patient with gonorrhea who has presented at the clinic. The student should include which of the following in the care plan for this patient?
Correct Answer: D
Rationale: Correct Answer: D - The patient should also be treated for chlamydia. Rationale: 1. Gonorrhea and chlamydia often coexist, so it is crucial to treat both infections to prevent complications. 2. Treating only gonorrhea may not fully resolve the patient's symptoms or prevent reinfection. 3. Dual therapy for gonorrhea and chlamydia is recommended to ensure optimal care for the patient. Summary of Incorrect Choices: A: The patient may benefit from oral contraceptives - This is not directly related to the treatment of gonorrhea. B: The patient must avoid use of tampons - This is not a standard recommendation for managing gonorrhea. C: The patient is susceptible to urinary incontinence - This is not a typical complication of gonorrhea.
Question 7 of 9
A laboratory finding indicatiNveU oRf SDIICN iGs oTnBe .thCatO sMhows
Correct Answer: A
Rationale: The correct answer is A: decreased fibrinogen. In disseminated intravascular coagulation (DIC), there is widespread activation of coagulation leading to consumption of clotting factors like fibrinogen, resulting in decreased levels. Platelets are usually decreased, not increased, in DIC. Hematocrit may be elevated due to hemoconcentration but not directly related to DIC. Thromboplastin time would be prolonged, not decreased, in DIC due to consumption of clotting factors.
Question 8 of 9
A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond?
Correct Answer: C
Rationale: The correct answer is C because it accurately explains the physiological change in the eye that leads to the need for bifocals. As individuals age, there is a gradual thickening of the lens of the eye, which affects the eye's ability to accommodate for near vision. This thickening makes it harder for the eye to focus on close objects, necessitating the use of bifocals to correct this near vision issue. Choices A, B, and D are incorrect because they do not provide a scientifically accurate explanation for the need for bifocals in older individuals. Option A is dismissive and does not address the specific change in the eye that leads to the need for bifocals. Option B implies aging as a general concept without specifying the relevant change in the eye. Option D incorrectly states that the eye gets shorter as we age, which is not the reason for needing bifocals.
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.