ATI RN
test bank foundations of nursing Questions
Question 1 of 5
The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient�s skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?
Correct Answer: A
Rationale: The correct answer is A: Drink more water to prevent further dehydration. Given the patient's fair skin turgor, fatigue, weakness, warm and dry skin, elevated pulse rate, and slightly elevated urinary sodium level, these are signs of dehydration. Increasing water intake would help improve the patient's hydration status. Other choices are incorrect because B (calorie-dense fluids) does not address the dehydration issue, C (milk and dairy products) does not directly address the symptoms presented, and D (grapefruit juice) is not essential for hydration in this case.
Question 2 of 5
Spontaneous termination of a pregnancy is considered to be an abortion if
Correct Answer: A
Rationale: The correct answer is A because spontaneous termination of a pregnancy is considered an abortion if it occurs before 20 weeks gestation. This is based on the medical definition of abortion as the termination of a pregnancy before the fetus is able to survive outside the womb. Choices B, C, and D are incorrect as they do not accurately reflect the criteria for defining abortion. B and D are specific conditions related to the fetus and the presence of infection, while C refers to passing products of conception intact, which can happen in both spontaneous and induced abortions.
Question 3 of 5
The nurse is caring for a patient withClostridiumdifficile. Which nursing actions will have thegreatest impact in preventing the spread of the bacteria?
Correct Answer: D
Rationale: Correct Answer: D - Proper hand hygiene techniques Rationale: 1. Clostridium difficile is mainly spread through contact with contaminated surfaces. 2. Proper hand hygiene is the most effective way to prevent the spread of bacteria. 3. Hand hygiene removes bacteria from hands, reducing the risk of transmission. 4. Appropriate disposal (A) is important but doesn't directly prevent spread. Monthly in-services (B) and mandatory cultures (C) are not as effective as hand hygiene in preventing transmission.
Question 4 of 5
A patient has fallen several times in the pastweek when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse ismostappropriate in correcting this urinaryproblem?
Correct Answer: A
Rationale: The correct answer is A: Limit fluid and caffeine intake before bed. This recommendation addresses the issue of nocturia (frequent urination at night) by reducing the amount of urine produced before bedtime, therefore decreasing the need to get up during the night. Caffeine is a diuretic, so limiting its intake can also help reduce the frequency of urination. Choices B, C, and D do not directly address the underlying cause of nocturia and falling. Leaving the bathroom light on (choice B) may help with visibility but does not address the urinary problem. Kegel exercises (choice C) focus on pelvic floor muscles, not bladder muscles. Clearing the path to the bathroom (choice D) can prevent falls but does not address the urinary issue.
Question 5 of 5
A nurse administers an antimuscarinic to a patient.Which findings indicate the patient is having therapeutic effects from this medication? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Decrease in dysuria. Antimuscarinic medications target muscarinic receptors, which are involved in the contraction of smooth muscle in the bladder. Dysuria, or painful urination, is a common symptom of overactive bladder or bladder spasms, which can be relieved by antimuscarinics. Choices B, C, and D are related to other urinary symptoms such as urgency, frequency, and prostate size, respectively, which are not directly targeted by antimuscarinics. Therefore, only a decrease in dysuria indicates therapeutic effects of the medication.
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