ATI RN
Adult Health Med Surg Nursing Test Banks Questions
Question 1 of 5
A patient presents with painless, progressive visual field loss, particularly in the peripheral vision, in both eyes. Gonioscopy reveals an open iridocorneal angle. Which of the following conditions is most likely responsible for this presentation?
Correct Answer: A
Rationale: The presentation of painless, progressive visual field loss, especially in the peripheral vision, along with an open iridocorneal angle is characteristic of open-angle glaucoma. Open-angle glaucoma is a type of glaucoma where there is no physical obstruction to the outflow of aqueous humor from the eye, but there is gradual damage to the optic nerve over time. The gradual loss of peripheral vision is a common early symptom of open-angle glaucoma. It is essential to diagnose and manage open-angle glaucoma promptly to prevent irreversible vision loss.
Question 2 of 5
A nurse is preparing to perform a wound irrigation procedure for a patient with a contaminated wound. What solution should the nurse use for wound irrigation?
Correct Answer: B
Rationale: Normal saline is the preferred solution for wound irrigation because it is isotonic and will not damage healthy tissue or delay wound healing. It helps to remove debris and pathogens from the wound, promoting a clean environment for healing. Sterile water can be used if normal saline is not available, but it may cause cellular damage if used in large volumes. Hydrogen peroxide and Betadine solution are not recommended for wound irrigation as they can be cytotoxic to the tissues and interfere with the wound healing process. It's important for the nurse to use evidence-based practice and follow recommended guidelines to promote optimal wound healing outcomes.
Question 3 of 5
The APPROPRIATE nursing diagnosis to protect the patient from further injury is, which of the following?
Correct Answer: D
Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Patients with thrombocytopenia are at risk for injury due to potential bleeding complications. Therefore, the appropriate nursing diagnosis to protect the patient from further injury in this case would be "Risk for injury related to thrombocytopenia." This nursing diagnosis allows the nurse to assess for signs of bleeding, implement interventions to prevent injury, and closely monitor the patient's platelet levels to prevent complications.
Question 4 of 5
The nurse informs the patient and family that rehabilitation prior to discharge is BEST described as______.
Correct Answer: A
Rationale: Rehabilitation prior to discharge is best described as a period of ups and downs, physically and emotionally because it involves the recovery process after an illness, injury, or medical procedure. It is a challenging time where the patient may experience setbacks and improvements on their journey back to health. There can be physical challenges such as regaining strength and mobility, as well as emotional challenges like coping with the changes in their condition. Therefore, the rehabilitation process is often not smooth and can be a rollercoaster of progress and setbacks, both physically and emotionally.
Question 5 of 5
Right after endorsement and during the rounds, the incoming nurse observes that the IV fluid is at 800 cc level and not 400cc, as endorsed. What is the CORRECT information that she will chart?
Correct Answer: C
Rationale: The correct information that the incoming nurse should chart is that she received 800 cc of IV fluid. It is crucial for the charting to accurately reflect the actual situation to provide an accurate record for the patient's care. In this scenario, the discrepancy between the endorsed amount (400 cc) and the observed amount (800 cc) should be documented to ensure transparency and continuity of care. This deviation from the expected amount should be clearly recorded for proper monitoring and evaluation of the patient's condition.
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