ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 9
After instructing a primiparous patient about episiotomy care, which of the following indicates successful teaching?
Correct Answer: A
Rationale: Wiping the episiotomy area from front to back using a blotting motion helps prevent introducing bacteria from the rectal area to the vaginal area, reducing the risk of infection. This technique also avoids causing unnecessary trauma to the healing tissues. Ensuring proper hygiene is vital to prevent complications such as infection, which is crucial for the healing process after an episiotomy.
Question 2 of 9
A pregnant woman presents with severe lower abdominal pain and vaginal bleeding. On examination, cervical motion tenderness and unilateral adnexal tenderness are noted, along with an adnexal mass on the affected side. Which of the following conditions is the most likely cause of these symptoms?
Correct Answer: A
Rationale: The clinical presentation of severe lower abdominal pain and vaginal bleeding in a pregnant woman, along with cervical motion tenderness, unilateral adnexal tenderness, and an adnexal mass on the affected side, is highly concerning for an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of an adnexal mass and tenderness on one side is indicative of potential tubal involvement and can mimic symptoms of pelvic inflammatory disease. Prompt evaluation and management are crucial in ectopic pregnancy to prevent life-threatening complications associated with rupture of the fallopian tube.
Question 3 of 9
A nurse doubts that the physician has prescribed an unusually large dosage of a medication. The nurse ask the senior nurse on duty about the order if it is correct or wrong, the senior nurse tells the nurse that the order is correct. The nurse comply with the order and administer it to the patient. The patient eventually died. Who is liable for this situation.
Correct Answer: D
Rationale: The physician is ultimately responsible for prescribing the correct dosage of medication to the patient. However, the nurse also plays a critical role in ensuring patient safety by questioning any orders that appear to be unusual or incorrect. In this scenario, the nurse had doubts about the unusually large dosage but was reassured by the senior nurse that the order was correct. Both the physician and the nurse failed in their responsibilities, leading to the patient's unfortunate death. The senior nurse also shares liability as they provided incorrect guidance to the nurse administering the medication. Ultimately, the situation was a result of a breakdown in communication and adherence to proper procedures by both the physician and the nurse.
Question 4 of 9
A patient presents with chest pain that worsens with swallowing and is relieved by leaning forward. An electrocardiogram (ECG) shows diffuse ST-segment elevation. Which cardiovascular disorder is most likely responsible for these symptoms?
Correct Answer: D
Rationale: The given clinical presentation of chest pain that worsens with swallowing and is relieved by leaning forward along with diffuse ST-segment elevation on an ECG is highly suggestive of pericarditis. Pericarditis is the inflammation of the pericardium, the thin sac surrounding the heart. The symptoms of pericarditis can mimic those of myocardial infarction (heart attack) but can also be differentiated by certain characteristics such as the described positional chest pain, which is worsened by swallowing and relieved by leaning forward.
Question 5 of 9
Ms. C is at risk for refeeding syndrome that is caused by rapid feeding. What should be the priority action of the health care team to prevent complications associated with this syndrome?
Correct Answer: B
Rationale: Refeeding syndrome is a potentially dangerous condition that can occur in malnourished individuals when nutrition is reintroduced too quickly. It is characterized by shifts in electrolytes, fluid imbalance, and metabolic abnormalities. Monitoring for decreased bowel sounds, nausea, bloating, and abdominal distention is the priority action to prevent complications associated with refeeding syndrome. These symptoms can indicate gastrointestinal issues such as ileus or overfeeding, which can lead to further complications. Early recognition and intervention can help prevent serious consequences of refeeding syndrome.
Question 6 of 9
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 7 of 9
A nurse is preparing to assist with a bone marrow biopsy procedure for a patient. What action should the nurse prioritize to ensure patient comfort during the procedure?
Correct Answer: C
Rationale: Prioritizing the application of a topical anesthetic cream to the biopsy site is essential to ensure patient comfort during the bone marrow biopsy procedure. This will help numb the area where the biopsy needle will be inserted, reducing the pain and discomfort experienced by the patient. Administering intravenous sedation may not always be needed for a bone marrow biopsy and should be decided by the healthcare provider based on the patient's individual needs. Providing distraction techniques such as music or relaxation exercises can be helpful, but they may not be as effective at reducing the physical discomfort caused by the procedure. Allowing the patient to eat or drink up to one hour before the procedure is important for other reasons, such as preventing potential complications during sedation or anesthesia, but it is not directly related to ensuring comfort during the biopsy itself.
Question 8 of 9
A woman in active labor experiences persistent fetal malposition, with the fetus in a transverse lie presentation. What nursing intervention should be prioritized to address this abnormal labor presentation?
Correct Answer: B
Rationale: When a woman in active labor experiences persistent fetal malposition, such as a transverse lie presentation, assisting the mother into a hands-and-knees position is a nursing intervention to prioritize. This position can help encourage the fetus to rotate into a more favorable position for delivery, such as a head-down position. By placing the mother in a hands-and-knees position, gravity can assist in shifting the fetus to the correct position. This intervention is non-invasive and can be effective in promoting the progress of labor and avoiding the need for more invasive interventions like instrumental delivery or cesarean section. However, if the fetus does not rotate or if there are signs of fetal distress, further interventions may be necessary.
Question 9 of 9
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.