ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 5
A postpartum client who delivered via cesarean section expresses concerns about breastfeeding difficulties and worries about insufficient milk supply. What nursing intervention should be prioritized to address the client's concerns?
Correct Answer: A
Rationale: The correct nursing intervention to prioritize in this situation is providing education on techniques to improve latch and milk transfer. Cesarean section deliveries can sometimes pose challenges for breastfeeding initiation, but with proper education and support, many women can successfully breastfeed following a C-section. By teaching the client techniques to improve latch and milk transfer, the nurse can help address the client's concerns about breastfeeding difficulties and worries about insufficient milk supply. This proactive approach empowers the client to overcome breastfeeding challenges and increase their confidence in their ability to breastfeed successfully. Referring the client to a lactation consultant for specialized support may also be beneficial, but providing initial education on latch and milk transfer is crucial in this early postpartum period. Recommending formula feedings or discouraging breastfeeding may not be appropriate interventions, as they can affect the establishment of breastfeeding and undermine the client's breastfeeding goals.
Question 2 of 5
A postpartum client reports 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 ecchymosis (bruising) and significant swelling in the perineum despite analgesic medication suggests a potential complication such as a hematoma. A hematoma is a collection of blood that can occur due to trauma or during childbirth. It is important to notify the healthcare provider immediately so that further assessment and interventions, such as drainage of the hematoma, can be initiated promptly to prevent complications and alleviate the client's pain. Applying ice packs or encouraging the client to sit on a donut cushion may provide temporary relief but will not address the underlying issue of a potentially serious hematoma. Administering additional analgesic medication may not be effective in this case if the pain is primarily due to the hematoma. Prompt notification of the healthcare provider is crucial for proper management of this situation.
Question 3 of 5
The nurse did an admission procedure. The best position to be assumed by Roy is _____.
Correct Answer: B
Rationale: The best position for a patient to assume during an admission procedure, particularly for respiratory assessment, is the semi-fowler position at least 30 degrees. In the semi-fowler position, the patient's head and upper body are elevated to a 30-degree angle. This position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and enhancing chest expansion. It also facilitates breathing and allows for better assessment of respiratory status. Additionally, the semi-fowler position helps prevent aspiration and promotes comfort and relaxation for the patient during the admission procedure.
Question 4 of 5
To have a better analysis and interpretation of the findings, Nurse Carmi reviewed and compared them with other findings of previous researches on the same topic. This is done MAINLY by going back to which part of the study? The _____________.
Correct Answer: B
Rationale: Reviewing and comparing the findings with other researches on the same topic is done mainly by going back to the related literature and studies section of the study. This section provides a comprehensive overview of existing knowledge and research findings related to the topic being studied. By comparing the current findings with what has been previously discovered and reported by other researchers, Nurse Carmi can better analyze and interpret the results within the broader context of the existing body of knowledge. This helps in identifying the significance of the new findings, highlighting potential contributions to the field, and determining areas for further research or discussion.
Question 5 of 5
Which of the following nursing measures would the nurse LEAST CONSIDERS to Patient Ellie with oxytocin drip?
Correct Answer: D
Rationale: While all of the nursing measures listed are important considerations when managing a patient receiving oxytocin drip, the nurse would least consider informing the patient about potential complications. The reason for this is that it is the responsibility of the healthcare provider (such as the physician or advanced practice nurse) to inform the patient about potential complications of a medication or treatment. Nurses are instrumental in providing education and support to patients, but in the case of informing patients about potential complications, this task typically falls under the purview of the prescribing provider. The primary focus of the nurse in this situation would be to assess, administer, monitor, and educate the patient as appropriate, ensuring safe and effective care delivery.