ATI RN
foundations of nursing test bank Questions
Question 1 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.
Question 2 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 3 of 5
A nurse is performing a cultural assessment usingthe ETHNIC mnemonic for communication. Which area will the nurse assess for the “H”?
Correct Answer: B
Rationale: The correct answer is B: Healers. In the ETHNIC mnemonic, "H" stands for Healers, where the nurse assesses the individual's traditional healers, healthcare practices, and preferences for seeking healthcare. This is important in understanding the individual's cultural beliefs and practices related to health and treatment. Assessing "Health" (A) may be important, but it does not specifically address traditional healers. "History" (C) focuses on the individual's cultural background rather than healthcare practices. "Homeland" (D) pertains to the individual's place of origin, which is not directly related to healthcare communication.
Question 4 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 5 of 5
The nurse is teaching a patient preventative measures regarding vaginal infections. The nurse should include which of the following as an important risk factor?
Correct Answer: D
Rationale: The correct answer is D: Frequent douching. Douching disrupts the natural balance of vaginal flora, making the environment more susceptible to infections. High estrogen levels (A) can actually protect against vaginal infections. Late menarche (B) and nonpregnant state (C) are not direct risk factors for vaginal infections. In summary, frequent douching is the most significant risk factor as it disrupts the vaginal microbiome.
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