ATI RN
Foundations and Adult Health Nursing Study Guide Answers Questions
Question 1 of 9
A patient expresses frustration with the long wait times in the healthcare facility. What is the nurse's best response?
Correct Answer: B
Rationale: The nurse's best response in this situation is to listen actively to the patient's concerns, acknowledge the inconvenience they are experiencing, and offer support. It is essential to validate the patient's feelings and show empathy towards their frustration. By actively listening and addressing the patient's concerns, the nurse can help alleviate some of their frustration and build a positive rapport with the patient. This approach demonstrates respect for the patient's feelings and promotes effective communication in the healthcare setting. Dismissing or ignoring the patient's frustration can lead to further dissatisfaction and impact the quality of care provided.
Question 2 of 9
The type of incontinence Patient Tita manifests, where there is involuntary loss of urine as a result of sneezing, coughing or even changing position is called ________.
Correct Answer: B
Rationale: The type of incontinence that Patient Tita is demonstrating, with involuntary loss of urine occurring as a result of activities such as sneezing, coughing, or changing position, is known as stress incontinence. Stress incontinence occurs when there is increased pressure on the bladder, causing the sphincter muscles to weaken and leading to urine leakage. Activities that physically stress or put pressure on the bladder, such as the ones mentioned, can trigger episodes of stress incontinence.
Question 3 of 9
A woman in active labor demonstrates persistent fetal malpresentation, with the fetus in a transverse lie position. What nursing intervention should be prioritized to address this abnormal labor presentation?
Correct Answer: C
Rationale: In cases of persistent fetal malpresentation, such as a transverse lie position, a cesarean section is often the safest and most effective intervention to address the abnormal labor presentation. Delivering a baby in a transverse lie position vaginally is associated with high risks, including fetal complications such as umbilical cord prolapse and head entrapment. Therefore, to ensure the safety of both the mother and the baby, a cesarean section is usually the most appropriate and timely intervention to address this situation. It is crucial to prioritize the immediate preparation and facilitation of a cesarean section in cases of persistent fetal malpresentation to prevent potential complications and ensure the best outcome for the mother and the baby.
Question 4 of 9
Which of the following actions is appropriate for managing a conscious patient with a suspected heat cramp?
Correct Answer: C
Rationale: Providing oral rehydration with electrolyte solutions is the appropriate action for managing a conscious patient with suspected heat cramps. Heat cramps are muscle pains or spasms that often occur during intense exercise in hot environments when a person sweats excessively, losing both fluids and electrolytes. Replenishing lost fluids and electrolytes through oral rehydration helps address the underlying cause of the cramps and provides relief to the patient. Massaging the affected muscles vigorously can potentially worsen the condition, applying cold packs is not usually recommended for heat-related conditions, and encouraging the patient to continue strenuous activity can lead to further complications.
Question 5 of 9
A woman in active labor is diagnosed with uterine rupture. What is the priority nursing action?
Correct Answer: A
Rationale: The priority nursing action for a woman diagnosed with uterine rupture during labor is to prepare for immediate cesarean section. Uterine rupture is a serious obstetric emergency that can lead to severe maternal and fetal complications, including hemorrhage, fetal distress, and injury to both mother and baby. A cesarean section is necessary to deliver the baby promptly and address any potential complications, such as controlling bleeding and ensuring the safety of both the mother and the baby. Time is critical in these situations, and prompt surgical intervention is essential to optimize outcomes. Administering intravenous oxytocin or assisting the mother into a hands-and-knees position would not address the immediate risks associated with uterine rupture. Initiating cardiopulmonary resuscitation (CPR) is only necessary if the mother's condition deteriorates to the point of cardiac or respiratory arrest, which may occur as a result of significant hemorrhage or other complications associated with uterine
Question 6 of 9
One evening, Jose complained of dyspnea despite continuous oxygen therapy. What should be the nurse's INITIAL intervention?
Correct Answer: C
Rationale: If Jose is complaining of dyspnea despite continuous oxygen therapy, the nurse's initial intervention should be to assess the patency of the tubing delivering the oxygen. A blockage in the tubing could restrict the flow of oxygen to the patient, leading to inadequate oxygen delivery and worsening dyspnea. By ensuring the tubing is clear and functioning properly, the nurse can address a potential issue with oxygen delivery before considering other interventions like giving PRN medication or involving the physician. Re-assessing the patient would also be important after ensuring the tubing's patency to evaluate the effectiveness of the intervention.
Question 7 of 9
A document that lists the medical treatment a person chooses to refuse if unable to make decisions is the:
Correct Answer: B
Rationale: A living will is a legal document that allows an individual to express their wishes regarding medical treatment in the event they become unable to make decisions. It specifically outlines the medical treatments a person chooses to refuse or accept under certain circumstances. It is important to differentiate a living will from a durable power of attorney, which designates someone to make healthcare decisions on behalf of the individual when they are unable to do so, and advance directives, which encompass both a living will and a durable power of attorney for healthcare. The living will serves as a guide for healthcare professionals and family members to honor the individual's preferences for medical care.
Question 8 of 9
A pregnant woman presents with painless, bright red vaginal bleeding at 34 weeks gestation. On examination, the cervix is found to be closed. Which of the following conditions is the most likely cause of these symptoms?
Correct Answer: C
Rationale: Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to painless vaginal bleeding during pregnancy. In the scenario described, the painless, bright red vaginal bleeding at 34 weeks gestation with a closed cervix is classic for placenta previa. This condition is more common in the third trimester and can be diagnosed through ultrasound. It is important to manage placenta previa carefully to prevent complications such as severe bleeding, preterm birth, and maternal/fetal distress.
Question 9 of 9
Mr. C is an older patient with a known history of peripheral vascular disease. The nurse places a heating pad directly on the patient's lower leg to relieve muscle spasms. The heating pad causes a burn, the area becomes infected, and the patient eventually must have a skin graft. This is an example of which of the following?
Correct Answer: D
Rationale: Negligence refers to the failure to take proper care in doing something. In this scenario, the nurse failed to exercise the standard of care expected in placing a heating pad directly on Mr. C's lower leg, knowing his history of peripheral vascular disease. This failure led to a burn and subsequent infection that required a skin graft for treatment. The actions of the nurse were negligent as they did not meet the expected standard of care, resulting in harm to the patient. This situation does not fit the definition of assault, malpractice, or vicarious liability, making negligence the most appropriate choice.