ATI RN
Adult Health Med Surg Nursing Test Banks Questions
Question 1 of 5
A postpartum client who experienced a third-degree perineal laceration expresses concerns about the healing process and potential complications. What nursing intervention should be prioritized to promote optimal wound healing?
Correct Answer: D
Rationale: Third-degree perineal lacerations are significant injuries that require careful monitoring for signs of infection or wound dehiscence, which are potential complications that could hinder optimal wound healing. Signs of infection may include increased redness, warmth, swelling, pain, and purulent drainage from the wound site. Dehiscence refers to the separation of the wound edges, which can be a serious complication requiring immediate attention. By closely monitoring the incision site for these signs, the nurse can promptly intervene if any complications arise, ensuring proper healing and preventing further complications. While providing perineal care, proper application of peri-pads, and encouraging sitz baths are important for comfort and cleanliness, monitoring for complications takes priority in promoting optimal wound healing in this scenario.
Question 2 of 5
Which of the following is a common complication associated with untreated clubfoot in infants?
Correct Answer: B
Rationale: Hip dysplasia is a common complication associated with untreated clubfoot in infants. If clubfoot is not treated promptly and properly, it can lead to abnormal development of the hip joint, resulting in hip dysplasia. This condition involves the abnormal formation of the hip socket, which can cause instability and potential dislocation of the hip joint. Early identification and treatment of clubfoot are important in preventing complications such as hip dysplasia.
Question 3 of 5
Which assessment findings is INDICATIVE of the diagnosis of hypertension?
Correct Answer: D
Rationale: The assessment finding that is indicative of the diagnosis of hypertension is consistent evaluation of blood pressure. Hypertension is diagnosed based on repeated measurements of elevated blood pressure. Consistently high blood pressure readings, usually defined as systolic blood pressure consistently at or above 140 mmHg and diastolic blood pressure consistently at or above 90 mmHg, are a key factor in diagnosing hypertension. Family history of high blood pressure (
Choice
A), elevation of blood cholesterol level (
Choice
B), and a stressful work environment (
Choice
C) may be risk factors for hypertension but are not diagnostic criteria. In order to diagnose hypertension, healthcare providers rely on consistent measurement and evaluation of blood pressure over time.
Question 4 of 5
A nurse is preparing to perform a colposcopy procedure for a patient with abnormal cervical cytology results. What action should the nurse prioritize to enhance patient comfort during colposcopy?
Correct Answer: B
Rationale: The best action the nurse should prioritize to enhance patient comfort during a colposcopy procedure is to explain the procedure steps and provide emotional support to the patient. Colposcopy is a procedure that involves examining the cervix, vagina, and vulva closely. Patients may feel anxious or uncomfortable during the procedure due to the sensitive nature of the area being examined and the potential concerns related to abnormal cervical cytology results. By explaining the procedure steps in detail before starting and providing emotional support, the nurse can help alleviate the patient's fears and anxieties, thereby enhancing their comfort and promoting a more positive experience overall. Additionally, establishing good communication and trust with the patient can also improve their cooperation during the procedure. Administering sedation, applying a topical anesthetic cream, and allowing a support person to be present are all important factors in providing holistic care as well, but the initial priority should be on communication and emotional support.
Question 5 of 5
Using APCAR Score, Nurse Lyca should bear in mind that this method of evaluating a newborn 's Condition is used at how many minutes after birth?
Correct Answer: C
Rationale: The APCAR (Appearance, Pulse, Grimace, Activity, Respiration) score is used to evaluate a newborn's condition in the first few minutes after birth. This assessment typically occurs within the first 1 to 3 minutes after the baby is born. The score helps healthcare providers quickly assess the baby's overall well-being and determine if any immediate interventions or further monitoring are necessary.