ATI RN
foundations of nursing test bank Questions
Question 1 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 2 of 5
A nurse who works in an oncology clinic is assessing a patient who has arrived for a 2-month follow-up appointment following chemotherapy. The nurse notes that the patients skin appears yellow. Which blood tests should be done to further explore this clinical sign?
Correct Answer: A
Rationale: The correct answer is A: Liver function tests (LFTs). Yellow skin can indicate jaundice, a sign of liver dysfunction, often seen in patients with liver issues or chemotherapy-related liver toxicity. LFTs including bilirubin, ALT, AST, and ALP can help assess liver function. B: Complete blood count (CBC) and C: Platelet count are not directly related to yellow skin and would not provide information on liver function. D: Blood urea nitrogen and creatinine are tests for kidney function, not liver function. While kidney dysfunction can sometimes cause yellow skin, LFTs are more specific for assessing liver function in this context.
Question 3 of 5
A nurse is teaching a patient about the urinarysystem. In which order will the nurse present the structures, following the flow of urine?
Correct Answer: B
Rationale: The correct order is B: Kidney, ureters, bladder, urethra. 1. Kidneys filter blood and produce urine. 2. Ureters transport urine from kidneys to bladder. 3. Bladder stores urine until expelled. 4. Urethra carries urine from bladder out of the body. Other choices are incorrect because they do not follow the anatomical flow of urine through the urinary system.
Question 4 of 5
A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient?
Correct Answer: B
Rationale: The correct answer is B because hearing loss and tinnitus caused by aspirin are typically irreversible. Aspirin is known to cause ototoxicity, which can lead to permanent damage to the auditory system. The nurse should inform the patient that the hearing loss and tinnitus may not improve even after discontinuing aspirin. Choice A is incorrect because hearing loss caused by aspirin is usually permanent. Choice C is incorrect because aspirin is a known cause of tinnitus and hearing loss. Choice D is incorrect because tolerance to aspirin does not prevent or reverse ototoxic effects like tinnitus and hearing loss.
Question 5 of 5
In determining malnourishment in a patient, which assessment finding is consistent with this disorder?
Correct Answer: C
Rationale: Step 1: Malnourishment often leads to iron deficiency anemia, causing spoon-shaped nails (koilonychia). Step 2: Koilonychia is a classic sign of chronic malnutrition and iron deficiency. Step 3: Moist lips (A) and pink conjunctivae (B) are not specific to malnourishment. Step 4: Not easily plucked hair (D) is more related to hair health rather than malnutrition.
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