ATI RN
foundation of nursing questions and answers Questions
Question 1 of 5
A nurse is pouching an ostomy on a patient withan ileostomy. Which action by the nurse ismostappropriate?
Correct Answer: B
Rationale: The correct answer is B, emptying the pouch if it is more than one-third to one-half full. This action is appropriate to prevent leakage and skin irritation. When the pouch becomes too full, it can put pressure on the seal, leading to potential leaks. Emptying the pouch at one-third to one-half fullness helps maintain a secure seal and prevents skin breakdown. Choice A is incorrect because changing the skin barrier portion of the ostomy pouch daily is unnecessary and can lead to skin irritation and breakdown. Choice C is incorrect because cleansing the skin around the stoma with soap and water excessively can strip the skin of its natural oils and cause irritation. Choice D is incorrect because leaving a 1/2-inch space around the stoma when measuring for the barrier device may result in an improper fit, leading to leakage and skin issues.
Question 2 of 5
Which patient ismostat risk for increased peristalsis?
Correct Answer: B
Rationale: The correct answer is B. Stress, like having three final examinations on the same day, can lead to increased peristalsis due to the activation of the sympathetic nervous system. This can result in faster movement of food through the digestive system. The other choices are incorrect because: A - Ignoring the urge to defecate does not directly relate to increased peristalsis. C - Major depressive disorder is more likely to be associated with decreased peristalsis due to the effects of stress on the body. D - Elderly individuals tend to have reduced peristalsis due to age-related changes in the digestive system.
Question 3 of 5
A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
Correct Answer: C
Rationale: The correct answer is C: Increase the patient's oral fluid intake. This is because severe diarrhea can lead to dehydration, which can be dangerous for patients with HIV infection. By increasing oral fluid intake, the patient can stay hydrated and prevent further complications. Administering antidiarrheal medications on a scheduled basis (Choice A) may provide temporary relief but does not address the underlying issue of dehydration. Encouraging the patient to eat balanced meals (Choice B) and increase activity level (Choice D) may be important for overall health but do not directly address the immediate concern of dehydration caused by severe diarrhea.
Question 4 of 5
A patient develops a foodborne disease fromEscherichiacoli. When taking a health history, which food item will the nursemostlikely find the patient ingested?
Correct Answer: B
Rationale: The correct answer is B: Undercooked ground beef. Escherichia coli is commonly found in undercooked ground beef, especially if it is contaminated during processing. Ground beef must be cooked to a safe internal temperature to kill any harmful bacteria. Improperly home-canned food (choice A) can also cause foodborne illnesses, but E. coli is more commonly associated with undercooked ground beef. Soft cheese (choice C) is often linked to Listeria contamination, not E. coli. Custard (choice D) is a less likely source of E. coli compared to undercooked ground beef.
Question 5 of 5
A nurse is caring for an 87-year-old Mexican-American female patient who is in end-stage renal disease. The physician has just been in to see the patient and her family to tell them that nothing more can be done for the patient and that death is not far. The physician offers to discharge the patient home to hospice care, but the patient and family refuse. After the physician leaves, the patients daughter approaches you and asks what hospice care is. What would this lack of knowledge about hospice care be perceived as?
Correct Answer: C
Rationale: The correct answer is C: A barrier to hospice care for this patient. The lack of knowledge about hospice care can be perceived as a barrier to accessing this type of care for the patient and her family. Understanding hospice care is crucial in making informed decisions about end-of-life care options. This lack of knowledge does not necessarily indicate lack of education (choice A), language barrier (choice B), or inability to grasp American concepts of health care (choice D), as hospice care is a universal concept that transcends cultural and educational backgrounds.
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