ATI RN
foundations of nursing test bank Questions
Question 1 of 5
A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient?
Correct Answer: B
Rationale: The correct answer is B because hearing loss and tinnitus caused by aspirin are typically irreversible. Aspirin is known to cause ototoxicity, which can lead to permanent damage to the auditory system. The nurse should inform the patient that the hearing loss and tinnitus may not improve even after discontinuing aspirin. Choice A is incorrect because hearing loss caused by aspirin is usually permanent. Choice C is incorrect because aspirin is a known cause of tinnitus and hearing loss. Choice D is incorrect because tolerance to aspirin does not prevent or reverse ototoxic effects like tinnitus and hearing loss.
Question 2 of 5
A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
Correct Answer: B
Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction. Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.
Question 3 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.
Question 4 of 5
A nurse obtained a telephone order from a primarycare provider for a patient in pain. Which chart entry should the nurse document?
Correct Answer: C
Rationale: The correct answer is C because it includes all necessary components for a complete and accurate chart entry. The nurse documents the date and time of the order, the medication prescribed (Morphine, 2 mg, IV every 4 hours), the indication for use (incisional pain), the intended recipient (Dr. Day), the nurse's name (J. Winds), and confirmation of the read-back procedure. This entry ensures clarity, accountability, and proper communication among healthcare team members. Choice A is incorrect because it misses the recipient of the order (Dr. Day) and only includes the nurse's name in the read-back. Choice B is incorrect because it lacks the recipient of the order and the confirmation of the read-back procedure with the primary care provider. Choice D is incorrect because it does not specify the primary care provider who gave the order and misses the read-back confirmation with the provider.
Question 5 of 5
The hospice nurse is caring for a patient with cancer in her home. The nurse has explained to the patient and the family that the patient is at risk for hypercalcemia and has educated them on that signs and symptoms of this health problem. What else should the nurse teach this patient and family to do to reduce the patients risk of hypercalcemia?
Correct Answer: C
Rationale: Rationale: Option C is correct because adequate hydration helps prevent hypercalcemia by promoting the excretion of excess calcium in the urine. This reduces the risk of calcium buildup in the blood. Consuming 2 to 4 liters of fluid daily ensures proper hydration, which is crucial for patients at risk for hypercalcemia. Stool softeners (Option A) are not contraindicated and can help prevent constipation, which may be a side effect of some cancer treatments. Laxatives (Option B) should not be taken daily as they can lead to dehydration and electrolyte imbalances. Restricting calcium intake (Option D) is not the primary intervention for preventing hypercalcemia; rather, maintaining adequate hydration is key.
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