ATI RN
Adult Health Nursing Study Guide Answers Questions
Question 1 of 9
A patient admitted to the ICU develops septic shock with refractory hypotension despite fluid resuscitation. Which intervention should the healthcare team prioritize to improve the patient's hemodynamic status?
Correct Answer: A
Rationale: In a patient with septic shock and refractory hypotension despite fluid resuscitation, the healthcare team should prioritize administering vasopressor medications to increase systemic vascular resistance. Vasopressors such as norepinephrine or vasopressin can be used to support blood pressure and perfusion to vital organs by constricting blood vessels and improving blood flow. By increasing systemic vascular resistance, vasopressors help to counteract the excessive vasodilation seen in septic shock and improve hemodynamic stability. It is crucial to address hypotension promptly in septic shock to prevent organ dysfunction and failure. Other interventions, such as fluid removal through continuous renal replacement therapy, assessing cardiac function with echocardiogram, or optimizing oxygen delivery through a transfusion of packed red blood cells, may be considered based on specific patient factors but do not address the primary issue of inadequate perf
Question 2 of 9
A 32-year-old pregnant woman presents with painless vaginal bleeding at 10 weeks of gestation. On ultrasound, a gestational sac with no embryo is visualized within the uterus. Which of the following conditions is most likely to be responsible for these findings?
Correct Answer: C
Rationale: In a missed abortion, the embryo has died, but the products of conception remain in the uterus, leading to the visualization of a gestational sac without an embryo on ultrasound. This is a type of missed miscarriage where the woman may not have any symptoms initially and the diagnosis is made during a routine ultrasound. The most common presenting symptom is painless vaginal bleeding. The absence of an embryo within the gestational sac can be confirmed through serial ultrasound examinations showing no fetal growth or cardiac activity. It is important for healthcare providers to provide appropriate counseling and management options to support the patient through this emotional experience.
Question 3 of 9
A nurse is preparing to perform a bladder catheterization for a patient with urinary retention. What action should the nurse prioritize to minimize the risk of infection?
Correct Answer: D
Rationale: Using aseptic technique and sterile equipment during catheter insertion is crucial for minimizing the risk of infection during bladder catheterization. Aseptic technique involves maintaining a sterile field, washing hands thoroughly, using sterile gloves, and ensuring that all equipment used is sterile. By following these practices, the nurse can prevent introducing bacteria into the urinary tract, reducing the likelihood of infection in the patient. While cleansing the perineal area with antiseptic solutions is important for general hygiene, the priority for infection prevention during catheterization lies in maintaining a sterile environment during the procedure. Administering prophylactic antibiotics is not routinely recommended for catheterization unless there are specific risk factors present.
Question 4 of 9
Which is the MOST appropriate intervention should the nurse do to help family perform the health tasks?
Correct Answer: B
Rationale: Helping the family recognize the problem is the most appropriate intervention to assist them in performing health tasks. By recognizing the problem, the family can better understand the need for action and be motivated to take steps to address it. This intervention enables the family to become more engaged in their healthcare decision-making process and enhances their ability to effectively manage their health tasks. It empowers them to seek appropriate health resources and make informed choices in promoting their health and well-being. Ultimately, by acknowledging the problem, the family is better equipped to initiate positive changes and improve their overall health outcomes.
Question 5 of 9
A primigravida at 39 weeks gestation presents to the labor and delivery unit with contractions every 5 minutes, lasting 45 seconds each. On examination, her cervix is dilated to 3 cm. What is the appropriate nursing intervention?
Correct Answer: A
Rationale: The appropriate nursing intervention in this case is to encourage the mother to walk to facilitate labor progression. The patient is in early labor with contractions every 5 minutes, lasting 45 seconds each, and her cervix is dilated to 3 cm. Encouraging the mother to walk can help gravity assist the descent of the baby and promote cervical dilation. Walking can also help alleviate some discomfort and encourage labor progression. It is important to promote natural, non-invasive methods to support the progress of labor before considering medical interventions such as oxytocin or cesarean section. Relaxation techniques can also be beneficial in managing pain during labor.
Question 6 of 9
A patient presents with redness, pain, and photophobia in the left eye. Slit-lamp examination reveals ciliary injection, corneal edema, and a mid-dilated pupil with fixed reaction to light. Which of the following conditions is most likely responsible for this presentation?
Correct Answer: A
Rationale: The presentation described in the question is classic for anterior uveitis. Anterior uveitis is an inflammatory condition affecting the iris and ciliary body and is characterized by redness, pain, and photophobia. Slit-lamp examination typically reveals ciliary injection (redness around the iris), corneal edema, and a mid-dilated pupil with a fixed reaction to light due to inflammation causing spasm of the iris muscles. Acute angle-closure glaucoma would present with similar symptoms but would also have increased intraocular pressure, which is not mentioned in the presentation. Endophthalmitis is an infection of the intraocular cavities and would typically present with more severe symptoms, such as severe pain, vision loss, and presence of pus in the eye. Corneal abrasion would present with pain, foreign body sensation, and possibly tearing but would not cause ciliary injection or fixed pupil reaction as
Question 7 of 9
In caring for this patient suffering from anorexia nervous, which task can be delegated to the nursing assistant?
Correct Answer: A
Rationale: Task A, obtaining special food for the patient when she requests it, can be delegated to the nursing assistant. This task involves simple assistance with gathering food items and does not require specific medical knowledge or interventions. Tasks B, C, and D involve more direct patient care and assessment, which should be performed by the nursing staff who have the necessary training and expertise to address the complexities of anorexia nervosa.
Question 8 of 9
A profession is characterized by the following except:
Correct Answer: C
Rationale: A profession is characterized by having a body of knowledge, a code of ethics, and engaging in research. However, being a member of a professional organization is not a defining characteristic of a profession. While many professionals may choose to join professional organizations for networking, support, and career advancement reasons, membership in such organizations is not universally required or exclusive to being considered a professional in a particular field. Hence, the presence or absence of professional organization membership does not determine the professional status of an individual.
Question 9 of 9
A woman in active labor experiences frequent and intense uterine contractions with minimal rest intervals, leading to maternal fatigue and decreased fetal oxygenation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
Correct Answer: B
Rationale: Uterine hyperstimulation, also known as tachysystole, is a condition characterized by frequent and intense uterine contractions with minimal rest intervals. This can lead to maternal fatigue and decreased fetal oxygenation due to the insufficient time for the uterus to relax and refill with oxygenated blood between contractions. Uterine hyperstimulation can be caused by various factors such as excessive use of uterotonics (oxytocin or prostaglandins), improper labor induction techniques, or maternal conditions like previous uterine surgery. It is essential for the nurse to assess for signs of uterine hyperstimulation and take appropriate interventions to prevent potential complications for both the mother and the baby.