ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 9
A patient is prescribed an opioid analgesic for postoperative pain management. Which nursing intervention is essential for preventing respiratory depression in the patient?
Correct Answer: B
Rationale: Monitoring oxygen saturation with pulse oximetry is essential for preventing respiratory depression in a patient prescribed an opioid analgesic. Opioid analgesics can suppress the respiratory drive, leading to respiratory depression. By constantly monitoring the patient's oxygen saturation levels with pulse oximetry, nurses can promptly detect any signs of respiratory depression and intervene early to prevent serious complications. This allows for timely adjustments in the medication dosage or administration of other supportive measures to maintain adequate oxygenation and prevent respiratory compromise. Administering naloxone prophylactically may be necessary in case of an opioid overdose but is not typically done as a preventive measure. Encouraging deep breathing exercises can help prevent respiratory complications postoperatively but may not be sufficient in the presence of opioid-induced respiratory depression. Administering bronchodilators as needed is not directly related to preventing respiratory depression caused by opioid analgesics.
Question 2 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 3 of 9
In planning the care of the elderly, which should be the important consideration that Nurse Gina has to consider _____.
Correct Answer: B
Rationale: Family support is a crucial consideration when planning the care of the elderly. The availability of family members to provide emotional support, assistance with daily activities, and decision-making can greatly impact the overall well-being of the elderly individual. Family support can help reduce feelings of isolation, ensure that the elderly person's needs are being met, and provide a sense of security and comfort. Additionally, involving family members in the care planning process can help create a collaborative and comprehensive care approach that considers the preferences and values of the elderly person. Considering the level of family support is essential for creating a care plan that meets the unique needs and circumstances of each elderly individual.
Question 4 of 9
A patient expresses frustration with the treatment plan proposed by the healthcare team. What is the most appropriate response from the nurse?
Correct Answer: B
Rationale: The most appropriate response from the nurse when a patient expresses frustration with the treatment plan proposed by the healthcare team is to empathize with the patient's frustration and explore their concerns further. It is important to actively listen to the patient, acknowledge their feelings, and address any questions or uncertainties they may have about the treatment plan. By engaging in open communication and demonstrating empathy, the nurse can foster a therapeutic relationship with the patient and work towards finding a solution that is mutually agreeable and beneficial for the patient's well-being. Dismissing the patient's concerns (Option A) or ignoring their frustration (Option C) can lead to a breakdown in communication and trust, which may ultimately impact the patient's compliance with the treatment plan. Similarly, telling the patient that they have no choice but to follow the treatment plan (Option D) can be perceived as dismissive and confrontational, which is not conducive to promoting patient-centered care.
Question 5 of 9
A patient with a history of heart failure is prescribed spironolactone. Which electrolyte imbalance is the patient at risk for developing with spironolactone therapy?
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic commonly used in the management of heart failure. One of the significant side effects of spironolactone is hyperkalemia, which is an elevated level of potassium in the bloodstream. Spironolactone works by blocking the action of aldosterone, a hormone that regulates potassium and sodium balance in the body. By inhibiting aldosterone, spironolactone reduces potassium excretion in the urine, leading to potential accumulation of potassium in the body.
Question 6 of 9
After the surgical procedure, the nurse assists with applying the surgical dressing. What is the nurse's priority action?
Correct Answer: B
Rationale: The nurse's priority action after applying the surgical dressing is to assess the surgical incision for signs of complications. This includes checking for any signs of infection, excessive bleeding, or other complications related to the surgical site. Early detection of such complications is crucial for ensuring proper healing and preventing serious complications. Once the assessment is done and any issues are addressed, the nurse can proceed with documenting the dressing change, providing instructions to the patient about wound care, and ensuring that the dressing is securely and correctly applied.
Question 7 of 9
Which of the following statements accurately describes the role of major histocompatibility complex (MHC) molecules in antigen presentation?
Correct Answer: B
Rationale: Major histocompatibility complex (MHC) class I molecules are responsible for presenting endogenous antigens, such as viral or intracellular proteins, to CD8+ T cells. These antigens are derived from within the cell, either synthesized within the cell itself or taken up from the cytoplasm. CD8+ T cells, also known as cytotoxic T cells, recognize antigens presented by MHC class I molecules and play a key role in cell-mediated immunity by destroying infected or abnormal cells.
Question 8 of 9
Nurse May is alarm by the incidence of number of young adults in the community with mental problems. Which of the following should be her PRIORITY nursing initiative?
Correct Answer: D
Rationale: The priority nursing initiative for Nurse May should be to set up a mental health program in the community. This proactive approach focuses on prevention, early intervention, and support for individuals experiencing mental health issues. By setting up a mental health program, Nurse May can address the root causes of mental problems in young adults in the community, provide education and awareness, offer counseling services, and promote mental well-being. This initiative can have a long-term impact on the mental health of individuals and help reduce the incidence of mental problems in the community. Setting up a mental health program is a holistic and sustainable approach to addressing mental health issues in the community.
Question 9 of 9
A woman in active labor is experiencing umbilical cord prolapse. What is the priority nursing action?
Correct Answer: B
Rationale: In the case of umbilical cord prolapse, the priority nursing action is to prepare for an immediate cesarean section. Umbilical cord prolapse is a serious obstetric emergency where the umbilical cord slips through the cervix ahead of the presenting part of the fetus. This can lead to compression of the cord, compromising fetal blood flow and oxygenation. Immediate delivery via cesarean section is necessary in order to prevent fetal hypoxia and avoid potential complications such as brain damage or death. Elevating the mother's hips or administering intravenous fluids rapidly may be interventions done in conjunction with preparing for a cesarean section, but the priority remains expedited delivery of the baby. Applying external fetal monitoring is not the most appropriate action in this emergency situation.