ATI RN
foundations of nursing test bank Questions
Question 1 of 5
A nurse who works in an oncology clinic is assessing a patient who has arrived for a 2-month follow-up appointment following chemotherapy. The nurse notes that the patients skin appears yellow. Which blood tests should be done to further explore this clinical sign?
Correct Answer: A
Rationale: The correct answer is A: Liver function tests (LFTs). Yellow skin can indicate jaundice, a sign of liver dysfunction, often seen in patients with liver issues or chemotherapy-related liver toxicity. LFTs including bilirubin, ALT, AST, and ALP can help assess liver function. B: Complete blood count (CBC) and C: Platelet count are not directly related to yellow skin and would not provide information on liver function. D: Blood urea nitrogen and creatinine are tests for kidney function, not liver function. While kidney dysfunction can sometimes cause yellow skin, LFTs are more specific for assessing liver function in this context.
Question 2 of 5
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
Correct Answer: A
Rationale: The correct answer is A: Utilize a pressure-reducing mattress. This intervention is crucial for preventing pressure ulcers in patients at risk for impaired skin integrity, such as those with HIV. By redistributing pressure, a pressure-reducing mattress helps to alleviate pressure on vulnerable areas, reducing the risk of skin breakdown. Limiting physical activity (B) can lead to muscle atrophy and worsen skin integrity. Applying antibiotic ointment (C) may not address the root cause of skin breakdown. Avoiding synthetic fabrics (D) may be helpful in some cases, but it is not as effective as using a pressure-reducing mattress.
Question 3 of 5
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 4 of 5
A patient has just returned to the postsurgical unit from post-anesthetic recovery after breast surgery for removal of a malignancy. What is the most likely major nursing diagnosis to include in this patients immediate plan of care?
Correct Answer: A
Rationale: The correct answer is A: Acute pain related to tissue manipulation and incision. This is the most likely major nursing diagnosis because post-surgical pain is a common and expected occurrence after breast surgery. The patient is likely to experience pain due to tissue manipulation and incision during the surgery. Addressing acute pain is crucial for the patient's comfort, well-being, and overall recovery. Choice B (Ineffective coping related to surgery) may be a secondary nursing diagnosis, but acute pain takes priority as it directly impacts the patient's immediate comfort and recovery. Choice C (Risk for trauma related to post-surgical injury) is not the most appropriate nursing diagnosis since the patient has already undergone surgery and is not at risk for further injury at this point. Choice D (Chronic sorrow related to change in body image) is not the most immediate concern post-surgery; addressing acute pain is more critical.
Question 5 of 5
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.
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