ATI RN
Adult Health Nursing Test Banks Questions
Question 1 of 9
A patient receiving palliative care for end-stage liver disease experiences severe pruritus. What intervention should the palliative nurse prioritize to address the patient's symptoms?
Correct Answer: D
Rationale: In end-stage liver disease, pruritus (itching) can be a distressing symptom caused by the accumulation of bile salts in the skin due to impaired liver function. Cholestyramine and other bile acid sequestrants are the primary treatment for managing pruritus in these patients. These medications bind to the bile salts in the intestine, preventing their reabsorption and reducing the itching symptoms. Antihistamines may not be as effective for this type of pruritus since it is not histamine-mediated. Topical corticosteroids are generally not recommended for long-term use in liver disease due to the risk of systemic absorption and adverse effects. Avoiding hot showers or baths may provide some temporary relief but is not a definitive treatment. Therefore, prioritizing the prescription of cholestyramine or bile acid sequestrants would be the most appropriate intervention to address the severe pruritus in a patient with end-stage liver disease
Question 2 of 9
A nurse is delegating tasks to a nursing assistant. What principle should guide the nurse's delegation decisions?
Correct Answer: B
Rationale: When a nurse is delegating tasks to a nursing assistant, the principle that should guide the nurse's delegation decisions is assigning tasks based on the assistant's level of experience (Option B). It is essential to take into consideration the skills, competencies, and experience level of the nursing assistant to ensure that the tasks delegated are suitable for them to perform safely and effectively. Delegating tasks beyond the assistant's level of experience may result in errors, inefficiencies, or compromised patient care. Therefore, matching tasks with the assistant's experience level is crucial in successful delegation and providing quality patient care.
Question 3 of 9
Despite the short staffing, Nurse Cirila also has the responsibility to maintain safe environment for her pediatric patients. The following are the indicators that Nurse Cirila has achieved this goal, EXCEPT __________.
Correct Answer: C
Rationale: The indicators listed indicate measures that Nurse Cirila can take to maintain a safe environment for her pediatric patients. However, assessing the competencies of staff before delegating a task is more related to ensuring effective delegation and appropriate task assignment rather than directly ensuring a safe environment for patients. While it is important to delegate tasks to qualified staff, this specific action does not directly contribute to maintaining a safe environment in the same manner as the other indicators listed (proper waste disposal, infection control, emergency protocols).
Question 4 of 9
During the surgical procedure, the nurse notices a break in sterile technique by a member of the surgical team. What should the nurse do?
Correct Answer: C
Rationale: In this situation, it is crucial for the nurse to inform the surgeon immediately and request corrective action. Maintaining a sterile field during surgical procedures is essential to prevent infections and ensure patient safety. Any break in sterile technique should be addressed promptly to prevent any potential harm to the patient. By informing the surgeon immediately, corrective action can be taken promptly to maintain the sterility of the surgical field and minimize the risk of complications. Reporting the incident to the surgeon also allows for immediate intervention and re-education of the team member involved in the break in sterile technique.
Question 5 of 9
In order to determine the patient's ability to concentrate and focus, which would be the PRIORITY nursing action?
Correct Answer: C
Rationale: Assessing the mental status of the patient is the PRIORITY nursing action to determine the patient's ability to concentrate and focus. This assessment includes evaluating the patient's level of alertness, orientation, memory, thought processes, and mood. By observing the patient's mental status, the nurse can gain valuable information about the patient's cognitive function, attention span, and ability to concentrate. This assessment will help guide further interventions and care planning for the patient. Asking for academic performance or conducting paper and pencil tests may be useful tools to assess concentration and focus, but they should come after a comprehensive evaluation of the patient's mental status. Referring the patient to a psychiatrist may be necessary based on the assessment findings, but it should not be the first step in determining the patient's ability to concentrate and focus.
Question 6 of 9
A patient presents with chest pain, dyspnea, and signs of hypotension. An electrocardiogram (ECG) shows ST- segment elevation in the inferior leads. Which cardiovascular disorder is most likely responsible for these symptoms?
Correct Answer: C
Rationale: Chest pain, dyspnea, hypotension, and ST-segment elevation on an ECG in the inferior leads are classic signs of an acute myocardial infarction (MI). An acute MI occurs when there is a sudden blockage of blood flow to a part of the heart muscle, leading to tissue damage. This causes symptoms such as chest pain due to ischemia, dyspnea due to heart failure, and hypotension due to poor cardiac output. The ST-segment elevation seen on the ECG is indicative of significant myocardial injury. Prompt diagnosis and management are crucial in acute MI to prevent further complications and to minimize damage to the heart muscle. It is important to differentiate an acute MI from stable or unstable angina or other cardiovascular disorders, as the management and prognosis vary significantly.
Question 7 of 9
A postpartum client presents with 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 persistent, severe perineal pain along with ecchymosis and swelling of the perineum can indicate a complication such as a hematoma. A hematoma is a collection of blood that can occur in the perineal area postpartum, usually as a result of trauma during delivery. It is essential to notify the healthcare provider immediately to assess the situation, provide appropriate treatment, and prevent further complications. Applying ice packs or administering additional analgesic medication may not address the underlying issue of a possible hematoma, so prompt medical evaluation is crucial in this situation.
Question 8 of 9
A patient in the ICU develops catheter-related bloodstream infection (CRBSI) associated with a central venous catheter. What intervention should the healthcare team prioritize to manage the patient's infection?
Correct Answer: A
Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.
Question 9 of 9
A patient presents with acute onset of severe vertigo, nausea, vomiting, and nystagmus. Symptoms are worsened with head movement. Which of the following neurological conditions is most likely responsible for these symptoms?
Correct Answer: B
Rationale: Vestibular neuritis is a condition characterized by the acute onset of severe vertigo, nausea, vomiting, and nystagmus. These symptoms are typically worsened by head movement. Vestibular neuritis is caused by inflammation of the vestibular nerve, which plays a key role in balance and spatial orientation. The classic presentation of these symptoms, along with the absence of hearing loss (which is seen in labyrinthitis), points towards vestibular neuritis as the most likely cause in this scenario. Meniere's disease presents with recurrent episodes of vertigo, hearing loss, tinnitus, and sensation of fullness in the ear. Benign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of vertigo triggered by changes in head position.