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
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.
Question 3 of 9
A woman in active labor experiences a prolonged latent phase, characterized by irregular contractions and minimal cervical dilation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
Correct Answer: A
Rationale: Maternal dehydration can lead to a prolonged latent phase in labor due to inadequate hydration affecting the progress of labor. Dehydration can cause decreased blood volume, leading to poor uterine perfusion and inefficient uterine contractions. It also contributes to reduced amniotic fluid volume and can lead to maternal exhaustion. Therefore, assessment and correction of maternal hydration status are crucial in improving labor patterns and preventing complications during labor and delivery.
Question 4 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 5 of 9
What is the PRIORITY of care for patient diagnosed with Guillain-Barre Syndrome?
Correct Answer: A
Rationale: The priority of care for a patient diagnosed with Guillain-Barre Syndrome is the maintenance of respiratory function. Guillain-Barre Syndrome can cause paralysis, including respiratory muscles, leading to respiratory failure. Ensuring adequate ventilation and oxygenation is crucial to prevent complications such as respiratory failure and the need for mechanical ventilation. Monitoring for signs of respiratory distress, such as shortness of breath, decreased oxygen saturation, and diminished lung sounds, is essential in providing prompt intervention and support for the patient's respiratory needs. Other aspects of care, such as prevention of decubitus ulcers, control of urinary tract infections, and replacement of fluid and electrolytes, are also important but not as immediate or life-threatening as ensuring adequate respiratory function in these patients.
Question 6 of 9
The newly-hired nurse oriented the caregiver hired by the couple. Which of the following should the nurse encourage the parents to do?
Correct Answer: A
Rationale: The nurse should encourage the parents to relate to each twin individually to enhance the attachment process. Building a strong attachment between the parents and each twin individually is vital for their emotional and psychological development. By spending quality one-on-one time with each twin, the parents can foster a unique bond with them, which can positively impact their relationship and overall development. This approach also helps prevent favoritism and ensures that each twin receives the attention and care they need to thrive.
Question 7 of 9
A nurse doubts that the physician has prescribed an unusually large dosage of a medication. The nurse ask the senior nurse on duty about the order if it is correct or wrong, the senior nurse tells the nurse that the order is correct. The nurse comply with the order and administer it to the patient. The patient eventually died. Who is liable for this situation.
Correct Answer: D
Rationale: The physician is ultimately responsible for prescribing the correct dosage of medication to the patient. However, the nurse also plays a critical role in ensuring patient safety by questioning any orders that appear to be unusual or incorrect. In this scenario, the nurse had doubts about the unusually large dosage but was reassured by the senior nurse that the order was correct. Both the physician and the nurse failed in their responsibilities, leading to the patient's unfortunate death. The senior nurse also shares liability as they provided incorrect guidance to the nurse administering the medication. Ultimately, the situation was a result of a breakdown in communication and adherence to proper procedures by both the physician and the nurse.
Question 8 of 9
One morning during rounds, Nurse Myra noticed that Marlene was unduly sad. The nurse 's BEST way of communicating her concern is _______.
Correct Answer: D
Rationale: Placing her hand over Marlene's shoulder and asking why the sad face is the best way for Nurse Myra to communicate her concern. This approach shows empathy and creates a safe space for Marlene to open up about her feelings. By using physical touch and showing genuine interest in Marlene's well-being, Nurse Myra can effectively address the situation and provide appropriate support or guidance as needed. Simply dismissing Marlene's feelings (option B and C) or resorting to religious advice (option A) may not effectively address the underlying cause of Marlene's sadness. It is important in situations like this to show empathy, compassion, and a willingness to listen in order to provide the best support for the individual in distress.
Question 9 of 9
A patient presents with a yellowish-white spot on the cornea, surrounded by a ring of inflammation. Slit-lamp examination reveals branching, filamentous opacities extending from the corneal lesion. Which of the following conditions is most likely responsible for this presentation?
Correct Answer: C
Rationale: The described clinical presentation of a yellowish-white spot on the cornea with a ring of inflammation, along with branching, filamentous opacities extending from the corneal lesion, is highly suggestive of fungal keratitis. Fungal keratitis is commonly caused by filamentous fungi such as Fusarium and Aspergillus species. The characteristic finding of branching, filamentous opacities seen on slit-lamp examination is classic for fungal infections of the cornea. It is important to promptly diagnose and treat fungal keratitis since delayed or inadequate management can result in vision-threatening complications.