ATI RN
Foundations and Adult Health Nursing Test Bank Questions
Question 1 of 4
A postpartum client expresses concerns about breastfeeding and worries about inadequate milk supply. What nursing intervention should be prioritized to address the client's concerns?
Correct Answer: A
Rationale: Assessing the infant's latch and feeding effectiveness should be prioritized as the initial nursing intervention to address the client's concerns about inadequate milk supply. Poor latch can lead to ineffective milk removal, which may result in decreased milk production. By ensuring the infant is latching correctly and effectively transferring milk, the client's milk supply can be optimized. Education about techniques to increase milk production can be provided following the assessment of feeding effectiveness. Referring to a lactation consultant may be necessary for further evaluation and support if issues persist despite correcting the latch. Supplemental formula feedings should be recommended as a last resort after all other interventions have been attempted and if there are concerns about inadequate nutrition for the infant.
Question 2 of 4
A postpartum client presents with sudden chest pain, dyspnea, and tachycardia. Which nursing action should be prioritized?
Correct Answer: D
Rationale: Sudden chest pain, dyspnea, and tachycardia in a postpartum client can be indicative of serious conditions such as pulmonary embolism or myocardial infarction. These conditions are emergencies that require immediate medical attention. Notifying the healthcare provider immediately is the priority to ensure prompt evaluation and intervention to address the potential life-threatening situation. While other nursing interventions such as elevating the head of the bed, providing supplemental oxygen therapy, and administering analgesics may be necessary, they should be done after notifying the healthcare provider to ensure appropriate management of the underlying cause.
Question 3 of 4
A postpartum client exhibits signs of wound infection, including erythema, warmth, and purulent drainage from a cesarean incision. Which nursing action is most appropriate?
Correct Answer: C
Rationale: When a postpartum client exhibits signs of wound infection, such as erythema, warmth, and purulent drainage from a cesarean incision, it is essential to notify the healthcare provider immediately. Wound infections can lead to serious complications if not promptly addressed. The healthcare provider will assess the infection, possibly order further diagnostic tests, and determine the appropriate course of treatment, which may include antibiotics or additional wound care measures. Applying a dressing or irrigating the wound may be part of the treatment plan prescribed by the healthcare provider, but the first step is always to seek guidance from the provider.
Question 4 of 4
A postpartum client exhibits signs of deep vein thrombosis (DVT), including calf pain, swelling, and warmth. Which nursing action is most appropriate?
Correct Answer: C
Rationale: Deep vein thrombosis (DVT) is a serious condition that requires prompt medical intervention. The presence of calf pain, swelling, and warmth in a postpartum client are concerning signs of a potential DVT. By notifying the healthcare provider immediately, appropriate diagnostic tests, such as ultrasound imaging, can be ordered to confirm the diagnosis. Timely treatment with anticoagulant medication can then be initiated to prevent complications such as pulmonary embolism. Applying warm compresses or encouraging ambulation may exacerbate the condition by promoting clot dislodgement, making immediate notification of the healthcare provider the most appropriate nursing action in this situation.