ATI RN
foundations of nursing test bank Questions
Question 1 of 9
A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe?
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. Chemotherapy commonly causes gastrointestinal side effects, such as nausea and vomiting, due to its impact on rapidly dividing cells in the digestive tract. This adverse effect can significantly impact a patient's quality of life and adherence to treatment. Pruritis (A), itching, is less common and usually not a primary side effect of chemotherapy. Altered glucose metabolism (C) is a potential effect of some chemotherapeutic agents but is not the most common adverse effect. Confusion (D) is not typically associated with chemotherapy and is more commonly seen with other medications or medical conditions.
Question 2 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 3 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 4 of 9
The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?
Correct Answer: D
Rationale: The correct answer is D: Mobility. A malignant breast tumor typically lacks mobility due to its fixed attachment to surrounding tissues. This characteristic is concerning for malignancy as it suggests invasive growth. Incorrect answers: A: Nontenderness - Tenderness does not reliably indicate malignancy or benignancy. B: A size of 5 mm - Tumor size alone does not determine malignancy. C: Softness and a regular shape - Malignant tumors are often firm and irregular in shape.
Question 5 of 9
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
Correct Answer: D
Rationale: The correct answer is D: Hold the condom by the cuff upon withdrawal. This is important because holding the condom by the cuff helps prevent any potential spillage of bodily fluids. During withdrawal, holding the condom by the base prevents it from slipping off and minimizes the risk of exposure to sexually transmitted infections. Explanation of why other choices are incorrect: A: Attaching the condom prior to erection is incorrect as it may lead to breakage or slipping off during intercourse. B: Reusing a condom with the same partner is highly discouraged due to the risk of breakage, reduced effectiveness, and potential exposure to infections. C: Using skin lotion as a lubricant is not recommended as it can degrade the condom material, increasing the risk of breakage.
Question 6 of 9
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 7 of 9
A patient, diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in health status would the nurse attribute to the patients metastatic brain disease?
Correct Answer: D
Rationale: The correct answer is D: Personality changes. Metastases to the brain can affect cognitive function and behavior, leading to personality changes. This is due to the impact on specific areas of the brain responsible for personality and behavior. Chronic pain (A) is more commonly associated with advanced cancer and not specific to brain metastases. Respiratory distress (B) is more likely related to lung cancer itself, not brain metastases. Fixed pupils (C) may indicate brainstem involvement, but personality changes are a more direct and common manifestation of brain metastases.
Question 8 of 9
The rate of obesity in the United States has reached epidemic proportions. Morbidity and mortality for both the mother and baby are increased in these circumstances. The nurse caring for the patient with an elevated BMI should be cognizant of these potential complications and plan care accordingly. Significant risks include (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Breech presentation. Obesity can lead to a larger fetus, increasing the risk of breech presentation. The rationale is that excess fat can hinder the baby's ability to turn head down. Other choices are incorrect because: B: Ectopic pregnancy is not related to obesity, C: Birth defects can be influenced by maternal health but are not directly linked to obesity, and D: Venous thromboembolism is more associated with immobility and hypercoagulable states rather than obesity.
Question 9 of 9
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.