ATI RN
Adult Health Nursing Test Banks Questions
Question 1 of 9
A woman in active labor is experiencing a shoulder dystocia during delivery. What nursing intervention should be prioritized?
Correct Answer: A
Rationale: Shoulder dystocia is an obstetric emergency where one of the baby's shoulders becomes impacted behind the mother's pubic bone after the head delivers. This can lead to compression of the umbilical cord and compromise fetal oxygenation. The most critical nursing intervention in managing shoulder dystocia is applying suprapubic pressure to dislodge the impacted shoulder and allow for delivery of the baby. By gently pushing downwards on the mother's abdomen just above the pubic bone, the shoulder can be released, and the baby can be delivered successfully. This intervention should be prioritized to prevent potential complications for both the mother and the baby. Episiotomy may be considered if necessary, but it is secondary to addressing the shoulder dystocia. Oropharyngeal airway insertion and administering magnesium sulfate are not indicated in the immediate management of shoulder dystocia.
Question 2 of 9
Which of the following structures is responsible for secreting bile, which aids in the emulsification and digestion of fats?
Correct Answer: A
Rationale: The liver is responsible for secreting bile, which aids in the emulsification and digestion of fats. Bile is produced by the liver and is stored and concentrated in the gallbladder before being released into the small intestine to help with the breakdown of fats during the digestion process. The gallbladder functions as a storage organ for bile produced by the liver. The pancreas secretes digestive enzymes and bicarbonate to aid in the digestion process, while the spleen is mainly involved in immune function and blood storage.
Question 3 of 9
A postpartum client presents with persistent, severe abdominal pain, tenderness, and rigidity. Which nursing action is most appropriate?
Correct Answer: C
Rationale: Persistent, severe abdominal pain, tenderness, and rigidity in a postpartum client can be indicative of serious conditions such as uterine rupture, hemorrhage, or infection, which require urgent medical attention. As a nurse, the priority action in this situation is to notify the healthcare provider immediately so that appropriate interventions can be initiated promptly to ensure the safety and well-being of the client. Administering analgesics or providing emotional support may not address the underlying cause of the symptoms and could potentially delay necessary medical treatment. Assisting the client to a comfortable position can be considered once the healthcare provider has been informed and appropriate assessments and interventions have been initiated.
Question 4 of 9
A patient with a history of angina pectoris is prescribed nitroglycerin sublingual tablets for chest pain relief. Which instruction should the nurse provide to the patient regarding nitroglycerin administration?
Correct Answer: C
Rationale: Nitroglycerin sublingual tablets are meant to be dissolved under the tongue to allow for rapid absorption into the bloodstream. Placing the tablet under the tongue helps to bypass the first-pass metabolism in the liver, leading to a quicker onset of action and chest pain relief. Chewing, swallowing, or applying the tablet to the skin will result in decreased effectiveness or delayed onset of action. Therefore, it is important for the patient to be instructed to place the nitroglycerin tablet under the tongue and allow it to dissolve for optimal therapeutic benefit.
Question 5 of 9
The patient has been ordered a regimen to treat a urinary tract infection and notifies the nurse that the patient's urine has turned an orange color. The nurse recognizes that the patient is most likely being treated with which drug?
Correct Answer: D
Rationale: Phenazopyridine HCl (Pyridium) is a medication commonly used to relieve the pain, burning, and discomfort associated with urinary tract infections (UTIs). One of the notable side effects of Phenazopyridine is the discoloration of urine, turning it a rusty-red or orange color. This color change is harmless and temporary, but it can be alarming to patients who are unaware of this side effect. Therefore, if a patient undergoing treatment for a UTI notices their urine has turned orange, it is most likely due to the administration of Phenazopyridine.
Question 6 of 9
Nurse Chona saw Patient Noel reading his own chart and question the nurse why (-) smoking and (-) liquor was recorded when he does not smoke and drink alcohol? What is the INITIAL explanation of Nurse Chona on the record?
Correct Answer: B
Rationale: Nurse Chona should explain to Patient Noel that the sign of negative before the word means that he is not drinking alcohol or smoking cigarettes. This is a simple misunderstanding and clarification should help clear up any confusion. It is important to uphold patient confidentiality and respect their autonomy, rather than reprimanding the patient for looking at their own chart. It is also essential to address any discrepancies in the patient's medical record to ensure accurate information is documented for proper treatment and care.
Question 7 of 9
Her parents usually become anxious and confused during late in the afternoon and after dark. What do you call this phenomenon?
Correct Answer: B
Rationale: Sundowning is a phenomenon commonly seen in elderly individuals, particularly those with cognitive impairments like dementia, where they become more restless, anxious, confused, or agitated during late afternoon and evening hours, typically around sunset. This change in behavior can manifest as increased confusion, wandering, aggression, or vocalization. The exact cause of sundowning is not completely understood but may involve a combination of factors such as disruptions in the sleep-wake cycle, fatigue, decreased lighting, and hormonal imbalances. Managing sundowning behaviors may involve environmental modifications, maintaining a regular routine, ensuring proper lighting, and addressing any underlying medical conditions contributing to the behavior changes.
Question 8 of 9
A patient receiving palliative care for end-stage liver cancer experiences severe nausea and vomiting despite antiemetic therapy. What should the palliative nurse consider when addressing the patient's symptoms?
Correct Answer: B
Rationale: When a patient receiving palliative care for end-stage cancer experiences severe nausea and vomiting despite current antiemetic therapy, the palliative nurse should consider switching to a different antiemetic medication with a different mechanism of action. This approach is based on the concept of individual variability in response to medications, as well as the potential development of tolerance to a particular drug. Switching to a different antiemetic with a new mechanism of action can provide the patient with a fresh chance at better symptom control by targeting different receptors or pathways involved in nausea and vomiting. It is important to consult the healthcare team and consider the patient's overall condition and medication history before making any changes in the treatment plan.
Question 9 of 9
The nurse ensures, which of the following should be present and be cooperative in the educational program?
Correct Answer: B
Rationale: In an educational program conducted by a nurse, it is crucial to involve the patient, their family, and significant others. This approach ensures holistic care by considering the patient's psychosocial environment, family dynamics, and support system. Including these individuals in the educational program fosters collaboration, strengthens the patient-nurse relationship, and equips family members with the knowledge and skills needed to provide optimal care at home. Furthermore, involving the patient's support system can enhance adherence to treatment plans and contribute to better health outcomes. Therefore, the presence and cooperation of the patient, family, and significant others are essential elements of a successful educational program led by a nurse.