ATI RN
foundations of nursing test bank Questions
Question 1 of 5
The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What is a priority nursing diagnosis for this patient?
Correct Answer: C
Rationale: The correct answer is C: Risk for infection related to altered immunologic response. This is the priority nursing diagnosis for a patient preparing for hematopoietic stem cell transplant (HSCT) because the patient's immune system will be severely compromised post-transplant, leading to a high risk of infections. It is crucial to prioritize infection prevention to ensure the patient's safety and well-being. Choice A is incorrect because while fatigue is common in cancer patients, it is not the priority in this case where infection risk is higher. Choice B is incorrect as altered nutrition can be addressed after managing the risk for infection. Choice D is incorrect as body image disturbance is important but not as critical as preventing infections in this highly vulnerable patient population.
Question 2 of 5
The nurse is performing an initial assessment of an older adult resident who has just relocated to the long-term care facility. During the nurses interview with the patient, she admits that she drinks around 20 ounces of vodka every evening. What types of cancer does this put her at risk for? Select all that apply.
Correct Answer: D
Rationale: The correct answer is D: Esophageal cancer. Alcohol consumption is a known risk factor for developing esophageal cancer. Ethanol, a component of alcohol, can damage the cells lining the esophagus and lead to the development of cancer over time. Incorrect choices: A: Malignant melanoma - Alcohol consumption is not directly linked to the development of malignant melanoma, a type of skin cancer. B: Brain cancer - There is no strong evidence linking alcohol consumption to an increased risk of brain cancer. C: Breast cancer - While excessive alcohol consumption is a risk factor for breast cancer, the primary association is with esophageal cancer in this case. E: Liver cancer - While alcohol abuse can lead to liver damage and increase the risk of liver cancer, the question specifies the types of cancer the patient is at risk for due to alcohol consumption, not the general risks associated with alcohol abuse.
Question 3 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 4 of 5
An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?
Correct Answer: D
Rationale: Correct Answer: D - Avoid rubbing or scratching the affected area Rationale: 1. Rubbing or scratching can further damage the already compromised skin integrity. 2. By avoiding rubbing or scratching, the patient reduces the risk of infection and delayed healing. 3. This intervention promotes skin healing and prevents worsening of the condition. Summary: A: Applying ice pack or heating pad may provide temporary relief but does not address the root cause of impaired skin integrity. B: Avoiding skin contact with water is not necessary and may not directly improve skin integrity. C: Phototherapy is not indicated for erythematous reactions to radiation therapy and may not address the issue.
Question 5 of 5
A nurse who sits on the hospitals ethics committee is reviewing a complex case that has many of the hallmarks of assisted suicide. Which of the following would be an example of assisted suicide?
Correct Answer: A
Rationale: The correct answer is A because administering a lethal dose of medication to a patient whose death is imminent directly causes the patient's death, constituting assisted suicide. This action is intentional and aims to end the patient's life. In contrast, choices B, C, and D do not involve intentionally causing the patient's death. Choice B involves a medication error but not with the intent to end the patient's life. Choice C respects the patient's autonomy in refusing treatment. Choice D honors the patient's wishes for end-of-life care. Thus, only choice A aligns with the definition of assisted suicide.