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
A nurse is caring for a patient who just underwentan intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse�sfirstpriorityin caring for this patient?
Correct Answer: C
Rationale: The correct answer is C: Monitor the patient for fever, rash, and difficulty breathing. The rationale is as follows: 1. Renal calculus obstruction can lead to complications such as infection, so monitoring for fever is crucial. 2. Rash can indicate an allergic reaction to the contrast dye used in the procedure. 3. Difficulty breathing may signal a severe reaction or complications. Summary: A: Turning the patient on the right side does not directly address the urgent need to monitor for potential complications. B: While fluid intake is important, it is not the immediate priority when the patient is at risk of developing complications. D: Administering narcotic medications may be necessary for pain relief but does not address the potential emergent issues related to the obstruction.
Question 3 of 5
Which intervention is the priority for the patient diagnosed with an intact tubal pregnancy?
Correct Answer: B
Rationale: The correct answer is B: Administration of methotrexate. This is the priority intervention for an intact tubal pregnancy to prevent further growth and potential rupture of the fallopian tube. Methotrexate is a medication used to stop the growth of the pregnancy tissue. Assessment of pain level (A) is important but not the priority as immediate intervention to address the ectopic pregnancy is crucial. Administration of Rh immune globulin (C) is not the priority in this situation, as it is typically given after a miscarriage or abortion to prevent Rh sensitization. Explanation of common side effects (D) is important for patient education, but it is not the immediate priority when dealing with an ectopic pregnancy.
Question 4 of 5
Initiate feeding.
Correct Answer: B
Rationale: The correct answer is B (2, 4, 1, 3, 5) because it follows the correct sequential order for initiating feeding. First, you need to prepare the food (2), then set up the feeding area (4), followed by inviting the person to eat (1), serving the food (3), and finally allowing them to eat (5). The other choices do not adhere to the logical sequence required for initiating feeding. Choice A and D have incorrect sequences of steps, while Choice C has steps 1 and 4 switched, which disrupts the proper order of initiating feeding.
Question 5 of 5
The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively?
Correct Answer: B
Rationale: The correct answer is B. By asking the patient to demonstrate the instillation of medications, the nurse can directly assess the patient's ability to self-administer the medications safely and effectively. This method allows for a practical demonstration of skills, which is more reliable than relying solely on verbal descriptions or past experiences. Choices A, C, and D are incorrect because assessing for previous inability, describing the method, or evaluating functional status may not directly demonstrate the patient's competency in self-administering ocular medications.
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