test bank foundations of nursing

Questions 102

ATI RN

ATI RN Test Bank

test bank foundations of nursing Questions

Question 1 of 5

A nurse is taking a history on a patient whocannot speak English. Which action will the nurse take?

Correct Answer: A

Rationale: The correct answer is A: Obtain an interpreter. This is the best action as it ensures effective communication and accurate understanding of the patient's history and needs. Using a professional interpreter maintains confidentiality, avoids misinterpretation, and promotes cultural sensitivity. Referring to a speech therapist (B) is not appropriate for language barriers. Letting a family member talk (C) may compromise privacy and accuracy. Finding a mental health nurse specialist (D) is not needed for language translation.

Question 2 of 5

Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely cause this abnormality?

Correct Answer: A

Rationale: The correct answer is A: Rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, which includes bilateral cataracts as a characteristic feature. Rubella virus can cross the placenta and affect the developing fetus. Cytomegalovirus (CMV) can also cause congenital cataracts, but rubella is more commonly associated with this abnormality. Syphilis can cause other congenital abnormalities but not bilateral cataracts. HIV does not typically lead to bilateral cataracts in newborns.

Question 3 of 5

A nurse is describing the purposes of a healthcare record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all thatapply.)

Correct Answer: A

Rationale: The correct answer is A: Communication. Healthcare records are essential for effective communication among healthcare providers to ensure continuity of care. They help convey important information about a patient's condition, treatment plan, and progress. Explanation: 1. Communication: Healthcare records facilitate communication between different healthcare team members, ensuring coordinated and efficient care delivery. 2. Legal documentation: While important, legal documentation is a separate purpose of healthcare records, not directly related to communication. 3. Reimbursement: Healthcare records are used for billing and reimbursement purposes, but this is not directly related to communication. 4. Nursing process: The nursing process involves assessment, diagnosis, planning, implementation, and evaluation of patient care, which is documented in healthcare records. However, this is not a primary purpose related to communication.

Question 4 of 5

A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in patients at risk for thrombocytopenia?

Correct Answer: C

Rationale: The correct answer is C: Epistaxis (nose bleed). Thrombocytopenia is a condition characterized by a low platelet count, leading to impaired blood clotting and an increased risk of bleeding. Epistaxis is a common symptom of thrombocytopenia due to the lack of platelets to aid in clot formation. Assessing for epistaxis in patients receiving carmustine is crucial to monitor and manage potential bleeding complications. Choices A, B, and D are incorrect as they are not directly associated with thrombocytopenia.

Question 5 of 5

A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond?

Correct Answer: C

Rationale: The correct answer is C because it acknowledges that many HIV patients use alternative therapies and emphasizes the importance of weighing the benefits and risks. This response shows respect for the patient's autonomy and preferences while also recognizing the need for informed decision-making. Choice A is incorrect because it dismisses complementary therapies outright without considering individual patient needs or preferences. Choice B is incorrect as it suggests avoiding alternative therapies entirely, which may not align with the patient's wishes or experiences. Choice D is incorrect as it presents a false dichotomy between alternative and medical approaches, disregarding the possibility of integrating both types of treatments.

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