ATI RN
Fundamentals of Nursing Nursing Process Questions Questions
Question 1 of 5
Within 20 minutes of the start of transfusion, the client develops a sudden fever. What is the nurse’s first action?
Correct Answer: D
Rationale: The correct answer is D: Stop the transfusion. This is the first action the nurse should take because the sudden fever could indicate a transfusion reaction. Stopping the transfusion is crucial to prevent further complications. Continuing to monitor vital signs (choice C) may delay necessary intervention. Forcing fluids (choice A) could worsen the situation if it is a reaction to the transfusion. Increasing the flow rate of IV fluids (choice B) is not indicated as the priority is to stop the transfusion to prevent a potential adverse event.
Question 2 of 5
The nurse is teaching a class about breast self-examinations. A client asks if the she should have an annual mammogram. According to the American Cancer Society, how should the nurse respond?
Correct Answer: B
Rationale: The correct answer is B: All women over age 40 should have an annual mammogram. The American Cancer Society recommends annual mammograms starting at age 40 for women with an average risk of breast cancer. This is based on evidence showing that regular mammograms starting at age 40 help in early detection and improve outcomes. Choice A is incorrect because the recommended age is 40, not 30. Choice C is incorrect as it focuses only on family history, while screening guidelines are based on overall risk factors. Choice D is incorrect because feeling at risk alone is not a sufficient indication for annual mammograms without considering other risk factors.
Question 3 of 5
During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
Correct Answer: B
Rationale: Step 1: Providing a solution of hydrogen peroxide and water as a mouth rinse helps in reducing the pain of stomatitis by promoting oral hygiene and preventing infections. Step 2: Hydrogen peroxide has antimicrobial properties that can help in reducing bacteria in the mouth, which can worsen stomatitis. Step 3: Rinsing with this solution can also help in cleansing the oral mucosa and reducing inflammation, thereby decreasing pain. Step 4: This intervention directly addresses the nursing diagnosis of impaired oral mucous membrane and is focused on symptom management. Summary: A: Recommending the client to discontinue chemotherapy is not a feasible option as it is essential for treating cancer. C: Monitoring platelet and leukocyte counts is important but does not directly address the pain of stomatitis. D: Checking for signs and symptoms is necessary but does not provide direct relief for the pain of stomatitis.
Question 4 of 5
A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
Correct Answer: D
Rationale: The correct answer is D: Leucovorin. Leucovorin is given during methotrexate therapy to protect normal cells by acting as a rescue agent that helps to reduce the toxic effects of methotrexate. It works by enhancing the efficacy of methotrexate in cancer cells while reducing its toxicity in normal cells. Probenecid (A) is not used to protect normal cells during methotrexate therapy. Cytarabine (B) and Thioguanine (C) are other chemotherapeutic agents and are not typically given to protect normal cells during methotrexate therapy.
Question 5 of 5
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (sub-arachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?
Correct Answer: B
Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage. 1. Positioning is crucial to prevent CSF leakage as the spinal block is administered into the sub-arachnoid space where CSF is present. 2. Incorrect Answers: A: Positioning is not related to preventing confusion in this context. C: Seizures are not typically associated with spinal block anesthesia. D: Cardiac arrhythmias are not directly impacted by the client's positioning for a spinal block.