ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 9
A nurse ________.
Correct Answer: D
Rationale: A nurse should have a sense of accountability for his actions. This means taking responsibility for one's decisions and behaviors while working in the healthcare setting. Accountability ensures that the nurse is aware of the consequences of his actions and is willing to accept ownership and follow through on commitments. It is a critical aspect of nursing practice as it helps maintain professional standards, promote patient safety, and uphold trust and integrity within the profession. Nurses are entrusted with the well-being of their patients, so being accountable for their actions is essential in providing high-quality care and maintaining ethical standards.
Question 2 of 9
Which of the following actions is recommended for controlling severe external bleeding from an extremity?
Correct Answer: C
Rationale: When controlling severe external bleeding from an extremity, the recommended action is to apply direct pressure with a sterile dressing. Direct pressure helps to stop the bleeding by promoting clot formation and reducing blood flow from the wound. This method is effective in most cases and should be the first response to control bleeding. Elevating the extremity above the level of the heart can be helpful in some cases, but direct pressure is the initial recommended action. Applying a tourniquet proximal to the injury site should only be done as a last resort when other methods are not successful, as it can lead to complications such as tissue damage. Removing any impaled objects can actually worsen the bleeding and should be avoided unless necessary for immediate life-saving measures.
Question 3 of 9
A nurse is caring for a patient who is refusing a prescribed treatment due to cultural beliefs. What action should the nurse take to address the patient's refusal?
Correct Answer: D
Rationale: The nurse should respect the patient's autonomy and collaborate on alternative treatment options. It is essential to honor the patient's cultural beliefs and preferences while also seeking to find a solution that aligns with the healthcare provider's recommendations. By working together with the patient to explore alternative treatment options that are acceptable within the patient's cultural framework, the nurse can promote patient-centered care and foster a trusting relationship with the patient.Ignoring or dismissing the patient's cultural beliefs can lead to decreased patient adherence and trust in the healthcare provider. Providing education and information to help the patient understand the treatment benefits is important, but it should be done in a way that respects the patient's autonomy and cultural perspective.
Question 4 of 9
During a shift handover, the nurse receives information about a patient's condition from the outgoing nurse. What action by the nurse demonstrates effective communication during the handover process?
Correct Answer: C
Rationale: Option C, summarizing key points and asking clarifying questions as needed, demonstrates effective communication during the handover process. This action ensures that the nurse fully understands the information being provided and helps to prevent misunderstandings or missing critical details. By summarizing key points, the nurse confirms their understanding and can ask for clarification on any areas that are unclear. Effective communication during handovers is essential for maintaining patient safety and continuity of care.
Question 5 of 9
A patient with a history of chronic obstructive pulmonary disease (COPD) is experiencing respiratory distress. Which nursing intervention is the priority for managing the patient's respiratory status?
Correct Answer: D
Rationale: Administering oxygen therapy is the priority nursing intervention for managing a patient with COPD experiencing respiratory distress. In COPD, the patient's lungs are less efficient at oxygen exchange, leading to hypoxemia. Oxygen therapy helps improve oxygenation in the body and alleviates respiratory distress in these patients. Positioning the patient in high Fowler's position can also help improve lung expansion, but providing supplemental oxygen takes precedence in addressing the underlying hypoxemia. Administering bronchodilators and performing chest physiotherapy aim to manage airway obstruction and promote airway clearance, but ensuring the patient has adequate oxygenation is crucial in the immediate management of respiratory distress in COPD.
Question 6 of 9
A nurse is preparing to assist with a bone marrow biopsy procedure for a patient. What action should the nurse prioritize to ensure patient comfort during the procedure?
Correct Answer: C
Rationale: Prioritizing the application of a topical anesthetic cream to the biopsy site is essential to ensure patient comfort during the bone marrow biopsy procedure. This will help numb the area where the biopsy needle will be inserted, reducing the pain and discomfort experienced by the patient. Administering intravenous sedation may not always be needed for a bone marrow biopsy and should be decided by the healthcare provider based on the patient's individual needs. Providing distraction techniques such as music or relaxation exercises can be helpful, but they may not be as effective at reducing the physical discomfort caused by the procedure. Allowing the patient to eat or drink up to one hour before the procedure is important for other reasons, such as preventing potential complications during sedation or anesthesia, but it is not directly related to ensuring comfort during the biopsy itself.
Question 7 of 9
A few days later, the patient comes into the emergency department via ambulance stretcher and reveals a work-up of blood sugar level at 800mg/dl, ketones are absent in the urine, she is dehydrated, and has an altered mental status. Based on the data, t he patient is most likely suferring from what specifi medical condition?
Correct Answer: A
Rationale: The patient's presentation with a blood sugar level of 800mg/dL, absence of ketones in the urine, dehydration, and altered mental status points towards Hyperosmolar nonketotic coma (HNKC). HNKC typically occurs in patients with Type 2 diabetes and is characterized by extremely high blood glucose levels (hyperglycemia) without significant ketosis. The absence of ketones in the urine distinguishes HNKC from Diabetic ketoacidosis (DKA). Patients with HNKC often present with severe dehydration, altered mental status, and hyperosmolarity. It is crucial to address the underlying cause of the hyperglycemia, correct dehydration, and normalize blood glucose levels promptly in the management of HNKC.
Question 8 of 9
Which of the following structures is responsible for producing hydrochloric acid and intrinsic factor, essential for the digestion of proteins and absorption of vitamin B12, respectively?
Correct Answer: B
Rationale: The stomach is responsible for producing hydrochloric acid and intrinsic factor. Hydrochloric acid helps in the breakdown of proteins during digestion, while intrinsic factor aids in the absorption of vitamin B12 in the small intestine. These two components are crucial for the proper functioning of the digestive system, particularly in breaking down food and absorbing essential nutrients. The liver is involved in bile production, the pancreas in the production of digestive enzymes, and the small intestine in nutrient absorption, but the specific functions related to hydrochloric acid and intrinsic factor are primarily attributed to the stomach.
Question 9 of 9
After several days in the hospital, the physician ordered the patient to be discharged. Which of the following is a PRIORITY restriction that you should emphasize when he goes home?
Correct Answer: D
Rationale: The priority restriction that should be emphasized when the patient is discharged from the hospital is the lifting of objects not more than 10 lbs. This is important to prevent any strain on the body, especially if the patient is still recovering or weak from their hospitalization. Lifting heavy objects can lead to complications, injuries, or setbacks in the recovery process. It is essential for the patient to follow this restriction to promote healing and avoid any further health issues.