Questions 9

ATI RN

ATI RN Test Bank

Adult Health Nursing Answer Key Questions

Question 1 of 5

A woman in active labor is receiving intravenous antibiotics for group B streptococcus (GBS) prophylaxis. What maternal assessment finding indicates a potential adverse reaction to the antibiotics?

Correct Answer: B

Rationale: Urticaria (hives) and pruritus (itching) are common signs of an allergic reaction to antibiotics, including those used for GBS prophylaxis during labor. Other signs of an adverse reaction may include flushing, fever, chills, and anaphylaxis. It is important to monitor the woman closely for any signs of an allergic reaction and to intervene promptly if one occurs to ensure the safety of both the mother and the baby.

Question 2 of 5

A patient admitted to the ICU develops delirium characterized by acute onset confusion and agitation. What intervention should the healthcare team prioritize to manage the patient's delirium?

Correct Answer: B

Rationale: The healthcare team should prioritize implementing environmental modifications to promote orientation in a patient with delirium. Delirium is a state of acute confusion and agitation that can be triggered by various factors such as medications, infections, or metabolic disturbances. Environmental modifications involve creating a calm, quiet, and well-lit environment for the patient. Promoting proper orientation through the use of clocks, calendars, and familiar objects can help reduce confusion and improve the patient's understanding of their surroundings. These interventions are non-pharmacological and aim to address the underlying causes of delirium while minimizing the need for additional medications that may have potential side effects. Antipsychotic medications and benzodiazepines should be used judiciously and under close supervision due to the risk of adverse effects in older adults and critically ill patients. Referring the patient to a psychiatrist may be considered if the delirium is complex or if there are underlying psychiatric issues contributing to the presentation.

Question 3 of 5

Nurse Filomena organized a health fair in one of the communities she covers, which was well attended, with several SCREENING TESTS being given simultaneously. What would Nurse Filomena consider the purpose of the health fair?

Correct Answer: C

Rationale: Nurse Filomena would consider the purpose of the health fair to be multiphasic screening. A multiphasic screening event involves offering various health screening tests at the same time to individuals within the community. These screenings aim to detect a range of health conditions early on, ultimately promoting prevention and early intervention. By organizing a health fair with several screening tests being given simultaneously, Nurse Filomena's primary goal is likely to help identify health issues in the community proactively and provide education and resources for ongoing health promotion and disease prevention. While aspects of community service, community bonding, and case finding may also be outcomes of the health fair, the focus on conducting multiple screening tests aligns most closely with the concept of multiphasic screening as the primary purpose.

Question 4 of 5

The presence of any of these risk factors means that ______.

Correct Answer: B

Rationale: The presence of risk factors indicates an increased likelihood or susceptibility to developing a particular disease. While risk modification and healthy lifestyle choices can help reduce the risk, having these risk factors still increases the overall chances of getting the disease compared to individuals without the same risk factors. It is essential for individuals with risk factors to be proactive in managing their health to mitigate the increased risk.

Question 5 of 5

A woman in active labor is experiencing umbilical cord prolapse. What is the priority nursing action?

Correct Answer: B

Rationale: In the case of umbilical cord prolapse, the priority nursing action is to prepare for an immediate cesarean section. Umbilical cord prolapse is a serious obstetric emergency where the umbilical cord slips through the cervix ahead of the presenting part of the fetus. This can lead to compression of the cord, compromising fetal blood flow and oxygenation. Immediate delivery via cesarean section is necessary in order to prevent fetal hypoxia and avoid potential complications such as brain damage or death. Elevating the mother's hips or administering intravenous fluids rapidly may be interventions done in conjunction with preparing for a cesarean section, but the priority remains expedited delivery of the baby. Applying external fetal monitoring is not the most appropriate action in this emergency situation.

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