ATI RN
foundation of nursing questions and answers Questions
Question 1 of 5
A nurse is a member of an interdisciplinary teamthat uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?
Correct Answer: C
Rationale: The correct answer is C: Document the variance in the patient�s record. By documenting the variance in the patient's record, the nurse can provide a clear record of the deviation from the critical pathway. This documentation is essential for tracking the patient's progress accurately and identifying potential issues that may require intervention. It allows for proper communication among the interdisciplinary team and ensures that everyone is aware of the deviation. Choice A is incorrect because adding data to the problem list may not provide a comprehensive record of the variance. Choice B is incorrect because focusing on charting using the DAR format does not address the deviation from the critical pathway. Choice D is incorrect because reporting a positive variance in the next team meeting may not accurately reflect the patient's actual progress and may lead to miscommunication within the team.
Question 2 of 5
The hospice nurse is caring for a 45-year-old mother of three young children in the patients home. During the most recent visit, the nurse has observed that the patient has a new onset of altered mental status, likely resulting from recently diagnosed brain metastases. What goal of nursing interventions should the nurse identify?
Correct Answer: D
Rationale: The correct answer is D. The goal of nursing interventions in this scenario is to teach family members how to interact with and ensure safety for the patient with impaired cognition. This is the most appropriate response because it addresses the immediate need to provide the patient with appropriate care and support in their home environment. By educating the family on how to interact with the patient and ensure their safety, the nurse can help maintain a sense of normalcy for the patient and promote their well-being. Choice A is incorrect because sedating the patient may not be the best approach without considering other interventions first. Choice B is incorrect as moving the patient to an acute-care facility may not be necessary or feasible at this time. Choice C is incorrect as it focuses on end-of-life care rather than addressing the immediate need of supporting the patient with altered mental status.
Question 3 of 5
A nurse is preparing to document a patient whohas chest pain. Which information is critical for the nurse to include?
Correct Answer: D
Rationale: The correct answer is D because documenting the patient's pain intensity using a pain scale (8 out of 10) is crucial for assessing the severity of the chest pain. This information helps in determining the appropriate intervention and monitoring the effectiveness of treatment. Choice A is irrelevant as it does not provide any useful information about the patient's condition. Choice B is important for neurological assessment but not specifically related to chest pain. Choice C is not as critical as knowing the current pain level.
Question 4 of 5
A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the management of the patients diarrhea?
Correct Answer: B
Rationale: The correct answer is B: Sandostatin. This drug is a somatostatin analog that can help manage HIV-related chronic severe diarrhea by reducing gastrointestinal secretions. Sandostatin works by inhibiting the release of various hormones and neurotransmitters in the gut, which can help control diarrhea in HIV patients. Rationale: A: Zithromax is an antibiotic that is not typically used to manage chronic severe diarrhea in HIV patients. C: Levaquin is also an antibiotic and not indicated for managing diarrhea in HIV patients. D: Biaxin is another antibiotic and not the appropriate choice for managing chronic severe diarrhea in HIV patients. In summary, Sandostatin is the correct choice as it specifically targets the underlying cause of diarrhea in HIV patients by reducing gastrointestinal secretions, whereas the other options are antibiotics that are not indicated for this purpose.
Question 5 of 5
A 27-year-old female patient is diagnosed with invasive cervical cancer and is told she needs to have a hysterectomy. One of the nursing diagnoses for this patient is disturbed body image related to perception of femininity. What intervention would be most appropriate for this patient?
Correct Answer: B
Rationale: The correct answer is B: Reassure the patient that she does not have to have sex to be feminine. Rationale: 1. Acknowledges patient's feelings: By reassuring the patient that she does not have to have sex to be feminine, the nurse validates the patient's emotions and concerns. 2. Addresses societal norms: This intervention challenges societal stereotypes that equate femininity solely with reproductive capabilities. 3. Promotes self-acceptance: Encouraging the patient to embrace her femininity beyond physical aspects fosters self-acceptance and self-worth. 4. Supports holistic care: Recognizing the multifaceted nature of femininity shows a holistic approach to addressing the patient's body image issues. Summary: A, C, and D are incorrect as they do not directly address the patient's specific concerns about her body image and femininity. Choice B is the most appropriate intervention as it validates the patient's feelings and challenges societal norms, promoting self-acceptance and holistic care
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