ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 9
A patient expresses concerns about the potential side effects of a prescribed medication. What is the nurse's best approach to address these concerns?
Correct Answer: B
Rationale: The nurse's best approach to address a patient's concerns about the potential side effects of a prescribed medication is to provide the patient with accurate information about potential side effects and management strategies. It is important for the nurse to acknowledge the patient's concerns, listen attentively, and offer clear explanations to help alleviate any fears or uncertainties. Providing accurate information can empower the patient to make informed decisions about their healthcare and feel more confident in taking the prescribed medication. Dismissing or ignoring the patient's concerns can lead to mistrust and non-adherence to the treatment plan. It is essential for the nurse to prioritize open communication and patient education to ensure the patient's well-being and compliance with the prescribed medication regimen.
Question 2 of 9
A patient in the ICU develops acute kidney injury (AKI) secondary to hypovolemic shock. What intervention should the healthcare team prioritize to manage the patient's renal function?
Correct Answer: A
Rationale: In a patient with acute kidney injury (AKI) secondary to hypovolemic shock, the priority intervention to manage the patient's renal function is to administer intravenous fluids to restore circulating volume. Hypovolemic shock leads to decreased blood flow to the kidneys, resulting in hypoperfusion and ischemic damage to the renal tubules. Prompt correction of hypovolemia with intravenous fluids helps improve renal perfusion and function by increasing blood flow to the kidneys. Adequate fluid resuscitation can potentially prevent further kidney damage and support kidney function recovery. It is crucial to address the underlying cause of AKI (hypovolemia in this case) to prevent complications and improve patient outcomes. Initiating renal replacement therapy or recommending nephrotoxic medications would not be the initial interventions for managing AKI in this scenario.
Question 3 of 9
Which of the following structures is responsible for the mechanical and chemical digestion of food, as well as the absorption of nutrients into the bloodstream?
Correct Answer: B
Rationale: The stomach is the organ responsible for the mechanical and chemical digestion of food. When food enters the stomach, it is mixed with stomach acid and enzymes to break down the food into smaller particles. This process helps prepare the food for further digestion and absorption of nutrients. The stomach also plays a key role in the absorption of some nutrients, such as certain vitamins and minerals. Additionally, the stomach's muscular contractions help mix the food with digestive enzymes and propel the partially digested food into the small intestine for further processing and absorption. The liver, pancreas, and large intestine have vital functions in the digestive system, but the stomach is the primary organ responsible for the initial digestion and absorption of nutrients.
Question 4 of 9
When can AIDS be manifested? The nurse answer was, "It can be as early as _______."
Correct Answer: B
Rationale: After being infected with the human immunodeficiency virus (HIV), it can take an average of 8-10 years before the development of Acquired Immunodeficiency Syndrome (AIDS) if left untreated. However, AIDS can manifest sooner in some cases, typically within 2 years, especially if the person's immune system is already significantly compromised or if they have other underlying health conditions. Thus, the manifestation of AIDS can vary, but it generally occurs within a range of 2 to 10 years after initial HIV infection.
Question 5 of 9
A woman in active labor is receiving intravenous antibiotics for group B streptococcus (GBS) prophylaxis. What maternal assessment finding indicates a potential adverse reaction to the antibiotics?
Correct Answer: B
Rationale: Urticaria (hives) and pruritus (itching) are common signs of an allergic reaction to antibiotics, including those used for GBS prophylaxis during labor. Other signs of an adverse reaction may include flushing, fever, chills, and anaphylaxis. It is important to monitor the woman closely for any signs of an allergic reaction and to intervene promptly if one occurs to ensure the safety of both the mother and the baby.
Question 6 of 9
Disclosure of client information beyond the interdisciplinary team without consent of the client is a breach of ______.
Correct Answer: A
Rationale: Confidentiality is the ethical principle that requires healthcare providers to keep client information private and not disclose it without the client's consent. When client information is shared beyond the interdisciplinary team without the client's consent, it breaches the trust and privacy expected in the nurse-client relationship. This breach not only violates the ethical principle of confidentiality but also undermines the client's autonomy and right to control their own personal information. Maintaining confidentiality is crucial for building trust and ensuring the well-being of the client.
Question 7 of 9
A patient receiving palliative care for end-stage heart failure experiences paroxysmal nocturnal dyspnea. What intervention should the palliative nurse prioritize to manage the patient's symptoms?
Correct Answer: B
Rationale: Elevating the head of the bed to improve respiratory mechanics is the most appropriate intervention for managing paroxysmal nocturnal dyspnea in a patient with end-stage heart failure. By keeping the head of the bed elevated, gravity helps reduce the pooling of fluid in the lungs, making it easier for the patient to breathe and reducing dyspnea. This strategy can help improve oxygenation and decrease the sensation of breathlessness, providing relief for the patient. Administering diuretic medications (Option A) can also be beneficial to reduce fluid overload, although positioning remains a key intervention. Encouraging the patient to sleep in a reclined position (Option C) can help alleviate symptoms, but specifically elevating the head of the bed is a more targeted approach. Referring the patient to a sleep specialist (Option D) may not be necessary at this time, as the primary concern is managing the acute symptom of paroxysmal nocturnal dyspnea
Question 8 of 9
A postpartum client reports persistent, severe perineal pain despite analgesic medication. On assessment, the nurse observes ecchymosis and swelling of the perineum. Which nursing action is most appropriate?
Correct Answer: C
Rationale: The presence of ecchymosis (bruising) and significant swelling in the perineum despite analgesic medication suggests a potential complication such as a hematoma. A hematoma is a collection of blood that can occur due to trauma or during childbirth. It is important to notify the healthcare provider immediately so that further assessment and interventions, such as drainage of the hematoma, can be initiated promptly to prevent complications and alleviate the client's pain. Applying ice packs or encouraging the client to sit on a donut cushion may provide temporary relief but will not address the underlying issue of a potentially serious hematoma. Administering additional analgesic medication may not be effective in this case if the pain is primarily due to the hematoma. Prompt notification of the healthcare provider is crucial for proper management of this situation.
Question 9 of 9
The nurse is conducting an assessment to her patient who has edema of the lower extremities due to congestive heart failure. If edema is graded on a scale of +1 (no visible edema in the leg) to 4+ (leg very swollen), what will the Nurse document in her chart if her assessment findings of the edema is SLIGHTLY swollen?
Correct Answer: B
Rationale: In the grading system used for edema, +1 indicates no visible edema in the leg, +2 indicates slight edema with indentations that quickly resolve, +3 indicates moderate edema with deeper indentations that may take longer to resolve, and +4 indicates severe edema with very swollen legs. In this case, since the edema is described as slightly swollen, the appropriate grade to document would be +2.