ATI RN
test bank foundations of nursing Questions
Question 1 of 5
The nurse is caring for a patient who has just been told that her ovarian cancer is terminal and that no curative options remain. What would be the priority nursing care for this patient at this time?
Correct Answer: A
Rationale: The correct answer is A: Provide emotional support to the patient and her family. This is the priority as the patient has received devastating news and needs immediate support. Emotional support can help the patient cope with the diagnosis, express feelings, and make decisions. B: Implementing distraction techniques may not address the patient's emotional needs in this critical situation. C: Offering to inform the family of the diagnosis is important but not the priority at this moment. D: Teaching about maintaining a positive attitude may not be appropriate as the patient is facing a terminal illness.
Question 2 of 5
A nurse administers an antimuscarinic to a patient.Which findings indicate the patient is having therapeutic effects from this medication? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Decrease in dysuria. Antimuscarinic medications target muscarinic receptors, which are involved in the contraction of smooth muscle in the bladder. Dysuria, or painful urination, is a common symptom of overactive bladder or bladder spasms, which can be relieved by antimuscarinics. Choices B, C, and D are related to other urinary symptoms such as urgency, frequency, and prostate size, respectively, which are not directly targeted by antimuscarinics. Therefore, only a decrease in dysuria indicates therapeutic effects of the medication.
Question 3 of 5
A 45-year-old woman comes into the health clinic for her annual check-up. She mentions to the nurse that she has noticed dimpling of the right breast that has occurred in a few months. What assessment would be most appropriate for the nurse to make?
Correct Answer: B
Rationale: The correct answer is B. Palpating the area for a breast mass is the most appropriate assessment in this scenario as dimpling of the breast can be a sign of underlying breast abnormalities such as a mass or tumor. By palpating the area, the nurse can determine if there is a lump or any other irregularity that may require further investigation. Choice A is incorrect because evaluating the patient's milk production is not relevant to the presenting symptom of breast dimpling. Choice C is incorrect as assessing the patient's knowledge of breast cancer does not address the immediate need for a physical assessment of the breast dimpling. Choice D is incorrect because assuming that the dimpling is just an age-related change without further assessment could delay potential diagnosis and treatment of a serious condition.
Question 4 of 5
A nurse is caring for a patient who just underwentan intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse’sfirstpriorityin caring for this patient?
Correct Answer: C
Rationale: The correct answer is C: Monitor the patient for fever, rash, and difficulty breathing. The rationale is as follows: 1. Renal calculus obstruction can lead to complications such as infection, so monitoring for fever is crucial. 2. Rash can indicate an allergic reaction to the contrast dye used in the procedure. 3. Difficulty breathing may signal a severe reaction or complications. Summary: A: Turning the patient on the right side does not directly address the urgent need to monitor for potential complications. B: While fluid intake is important, it is not the immediate priority when the patient is at risk of developing complications. D: Administering narcotic medications may be necessary for pain relief but does not address the potential emergent issues related to the obstruction.
Question 5 of 5
The nurse is caring for a patient of Hispanicdescent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Look at the patient when talking. This is important because maintaining eye contact shows respect, builds trust, and enhances communication with the patient. By looking at the patient, the nurse can also observe nonverbal cues and ensure the patient is engaged in the conversation. Choice A: Using long sentences can be overwhelming for a patient who may not understand the language, leading to miscommunication. Choice C: Using breaks in sentences may help the interpreter better convey the message, but looking at the patient is more essential for effective communication. Choice D: Looking at only nonverbal behaviors neglects the importance of eye contact and direct communication with the patient.
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