ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 9
A 45-year-old woman presents with heavy menstrual bleeding and iron deficiency anemia. On pelvic examination, the uterus is enlarged, and multiple irregularly shaped masses are palpated. Which condition is most likely to be responsible for these findings?
Correct Answer: A
Rationale: The clinical presentation of heavy menstrual bleeding, iron deficiency anemia, an enlarged uterus, and irregularly shaped masses palpated on pelvic examination is most indicative of leiomyomas, also known as uterine fibroids. Leiomyomas are benign smooth muscle tumors that commonly occur in women of reproductive age. They can lead to heavy menstrual bleeding and iron deficiency anemia due to their size and location within the uterus. On pelvic examination, leiomyomas can be felt as irregularly shaped masses within the uterine wall. This presentation is classic for leiomyomas and distinguishes them from conditions such as endometrial polyps, endometrial hyperplasia, and adenomyosis.
Question 2 of 9
In the performance of her role and functions a school nurse, which guiding principle should be consider very IMPORTANT?
Correct Answer: A
Rationale: The guiding principle that health is an integral part of the education process is of utmost importance for a school nurse in performing their role and functions. This principle emphasizes the interconnectedness of health and academic success, highlighting that healthy students are better able to learn and succeed in school. As a school nurse, understanding and prioritizing this principle means focusing on promoting health and wellness, providing healthcare services, and implementing health education programs to support the overall well-being and academic achievement of students. By recognizing the significance of this principle, school nurses can effectively contribute to creating a healthy and supportive school environment that fosters student growth and development.
Question 3 of 9
While preparing the operating room (OR) for a surgical procedure, the nurse notices a malfunctioning anesthesia machine. What is the nurse's priority action?
Correct Answer: C
Rationale: The nurse's priority action when noticing a malfunctioning anesthesia machine in the operating room should be to inform the anesthesia provider immediately. Anesthesia providers are responsible for administering anesthesia safely during surgical procedures, and they need to be made aware of any equipment issues promptly to ensure patient safety. Continuing with the surgical procedure using a malfunctioning anesthesia machine can pose serious risks to the patient's well-being. Using an alternative anesthesia machine may be an option, but informing the anesthesia provider first ensures that the appropriate action is taken to address the issue effectively. Documenting the malfunction in the equipment log is important for record-keeping purposes, but it should not take precedence over informing the anesthesia provider and taking immediate action to address the problem.
Question 4 of 9
A woman in active labor experiences a prolonged latent phase, characterized by irregular contractions and minimal cervical dilation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
Correct Answer: A
Rationale: Maternal dehydration can lead to a prolonged latent phase in labor due to inadequate hydration affecting the progress of labor. Dehydration can cause decreased blood volume, leading to poor uterine perfusion and inefficient uterine contractions. It also contributes to reduced amniotic fluid volume and can lead to maternal exhaustion. Therefore, assessment and correction of maternal hydration status are crucial in improving labor patterns and preventing complications during labor and delivery.
Question 5 of 9
As a nurse you are guided that pain is usually described BEST as a phenomenon which is a ________.
Correct Answer: B
Rationale: Pain is best described as a subjective unpleasant experience because it is unique to each individual and is influenced by a variety of factors including emotional, psychological, and cultural elements. Pain cannot be objectively measured or quantified, and therefore it is considered a subjective experience that is reported by the person experiencing it. This is why pain is often assessed using self-report scales and tools to capture the individual's perception of their pain intensity and quality.
Question 6 of 9
A nurse is preparing to perform a bedside bronchoscopy procedure for a patient. What action should the nurse take to ensure patient safety during the procedure?
Correct Answer: B
Rationale: The correct action for the nurse to ensure patient safety during a bedside bronchoscopy procedure is to obtain informed consent from the patient or their legal representative. Informed consent is a vital ethical and legal requirement before any medical procedure. It ensures that the patient understands the risks, benefits, and alternatives of the procedure, as well as gives the patient the authority to make decisions about their healthcare. By obtaining informed consent, the nurse ensures that the patient has been properly informed and agrees to undergo the bronchoscopy, which promotes patient autonomy and safety. Administering sedation, using topical anesthesia, and restricting food intake are also important aspects of bronchoscopy preparation, but obtaining informed consent is the primary action to prioritize patient safety.
Question 7 of 9
A patient presents with recurrent episodes of venous thrombosis, including deep vein thrombosis (DVT) and pulmonary embolism (PE), despite no apparent provoking factors. Which of the following conditions is most likely to cause these findings?
Correct Answer: D
Rationale: Factor V Leiden mutation is the most common inherited predisposition to venous thrombosis. In this condition, there is a specific mutation in the factor V gene (also known as factor V Leiden) that makes factor V resistant to inactivation by activated protein C. This resistance leads to excessive clot formation, increasing the risk of recurrent venous thrombosis like DVT and PE. Patients with Factor V Leiden mutation may have a history of recurrent unprovoked venous thrombosis at a young age. In comparison, antithrombin III deficiency, protein C deficiency, and protein S deficiency are other inherited thrombophilias that may increase the risk of venous thrombosis, but Factor V Leiden mutation is the most likely cause in this case based on the presentation of recurrent episodes without apparent provoking factors.
Question 8 of 9
A patient with a history of type 2 diabetes mellitus is prescribed insulin glargine (Lantus) once daily. Which statement indicates understanding of insulin glargine administration?
Correct Answer: C
Rationale: Insulin glargine (Lantus) is a long-acting insulin that is typically administered once daily at the same time each day to help maintain a steady level of insulin in the body. It is important to rotate injection sites within the same body region (such as the abdomen, thigh, or upper arm) to prevent lipodystrophy (lumpiness or dents in the skin) and to ensure consistent absorption of the insulin. Proper rotation of injection sites helps to prevent tissue damage and ensures optimal insulin absorption, improving the effectiveness of insulin therapy. It is not necessary to inject insulin glargine before meals, vigorously shake the vial, or administer it with a rapid-acting insulin.
Question 9 of 9
A nurse doubts that the physician has prescribed an unusually large dosage of a medication. The nurse ask the senior nurse on duty about the order if it is correct or wrong, the senior nurse tells the nurse that the order is correct. The nurse comply with the order and administer it to the patient. The patient eventually died. Who is liable for this situation.
Correct Answer: D
Rationale: The physician is ultimately responsible for prescribing the correct dosage of medication to the patient. However, the nurse also plays a critical role in ensuring patient safety by questioning any orders that appear to be unusual or incorrect. In this scenario, the nurse had doubts about the unusually large dosage but was reassured by the senior nurse that the order was correct. Both the physician and the nurse failed in their responsibilities, leading to the patient's unfortunate death. The senior nurse also shares liability as they provided incorrect guidance to the nurse administering the medication. Ultimately, the situation was a result of a breakdown in communication and adherence to proper procedures by both the physician and the nurse.