ATI RN
foundations of nursing test bank Questions
Question 1 of 5
During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?
Correct Answer: D
Rationale: The correct answer is D. The nurse should arrange for a referral to a rehabilitation facility for vision training. This option directly addresses the patient's inability to read medication bottles accurately due to a vision problem. Vision training can help improve the patient's ability to manage medication independently. A: Asking the social worker to investigate alternative housing arrangements is not relevant to the patient's vision problem affecting medication management. B: Asking the social worker to investigate community support agencies may not directly address the patient's vision issue and medication management. C: Encouraging the patient to explore surgical corrections for the vision problem is not appropriate without considering less invasive options first, such as vision training.
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 patient who is receiving care for osteosarcoma has been experiencing severe pain since being diagnosed. As a result, the patient has been receiving analgesics on both a scheduled and PRN basis. For the past several hours, however, the patients level of consciousness has declined and she is now unresponsive. How should the patients pain control regimen be affected?
Correct Answer: C
Rationale: The correct answer is C. When a patient's level of consciousness declines and becomes unresponsive, it may indicate a potential overdose of analgesics. To ensure patient safety, IV analgesics should be withheld and replaced with transdermal analgesics, which provide a more controlled and gradual release of medication. This switch helps prevent further overdose and adverse effects. Continuing the current pain control regimen (Choice A) may worsen the situation. Placing the pain control regimen on hold (Choice B) may lead to inadequate pain management. Reducing analgesic dosages (Choice D) may not be sufficient in addressing the overdose issue.
Question 4 of 5
Which findings should the nurse follow up on afterremoval of a catheter from a patient? (Select allthat apply.)
Correct Answer: B
Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection. A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal. C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem. D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.
Question 5 of 5
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.