During surgery, the nurse notices that the patient's temperature is dropping below the normal range. What should the nurse do?

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Question 1 of 9

During surgery, the nurse notices that the patient's temperature is dropping below the normal range. What should the nurse do?

Correct Answer: B

Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.

Question 2 of 9

What PRIORITY nursing action should you do with the presenting clinical manifestations of the patient?

Correct Answer: D

Rationale: Administering oxygen inhalation is the priority nursing action for a patient presenting with clinical manifestations related to endocrine disorders. Patients with hyperthyroidism, Cushing syndrome, and hypothyroidism can all experience respiratory distress due to various reasons such as thyroid storm, adrenal crisis, or myxedema coma. Oxygen inhalation helps improve oxygenation and tissue perfusion, providing immediate support to the patient's respiratory system. It is crucial to ensure adequate oxygenation before addressing other assessments or interventions. Once the patient's breathing is stabilized, further assessments and treatments can be initiated as necessary.

Question 3 of 9

A nurse is assessing a patient's pain using a pain rating scale. What action by the nurse demonstrates cultural competence in pain assessment?

Correct Answer: C

Rationale: Choosing option C, asking the patient about their cultural beliefs and preferences related to pain, demonstrates cultural competence in pain assessment. Pain experiences can vary greatly across different cultures, and a patient's cultural background can influence how they perceive and express pain. By inquiring about the patient's cultural beliefs and preferences, the nurse can gain a better understanding of the patient's perspective on pain. This information is crucial for providing individualized and culturally sensitive pain management interventions. It also shows respect for the patient's unique cultural background and helps build a trusting and collaborative relationship between the nurse and the patient.

Question 4 of 9

The universal health law focuses on the population. If a pregnant woman has been found and diagnosed to have preeclampsia, the focus of health care is on the ________.

Correct Answer: C

Rationale: When a pregnant woman is diagnosed with preeclampsia, the focus of health care shifts to the individual woman herself. Preeclampsia is a serious condition that affects the health of the pregnant woman and her unborn child. The healthcare team will prioritize the care and treatment of the woman to ensure her well-being and safety. In this scenario, the emphasis is on providing personalized and targeted care to address the needs of the individual patient, rather than a broader focus on population groups, communities, or families.

Question 5 of 9

A patient with a history of chronic obstructive pulmonary disease (COPD) presents with increased dyspnea and cough productive of purulent sputum. On auscultation, coarse crackles are heard bilaterally. Which complication of COPD is the patient most likely experiencing?

Correct Answer: A

Rationale: The patient with a history of COPD presenting with increased dyspnea, cough productive of purulent sputum, and coarse crackles on auscultation is most likely experiencing an acute exacerbation of COPD. Acute exacerbations in COPD are defined as sustained worsening of the patient's respiratory symptoms beyond normal day-to-day variations, leading to a change in medication. Common triggers for exacerbations include respiratory infections, air pollution, and non-compliance with medications.

Question 6 of 9

Sandro is taking pemoline (Cylert) for ADHD. The nurse must be aware of which of the following side effects?

Correct Answer: D

Rationale: Pemoline (Cylert) is a central nervous system stimulant used in the treatment of ADHD. One of the significant potential side effects of pemoline is hepatotoxicity, which can manifest as elevated liver function test results. Therefore, the nurse must monitor the patient's liver function regularly while they are taking pemoline to monitor for any signs of liver damage or dysfunction. It is essential to educate the patient about the signs and symptoms of liver problems, such as jaundice (yellowing of the skin or eyes), abdominal pain, nausea, or dark urine, and to report any such symptoms immediately to their healthcare provider. Regular monitoring and early detection of liver function abnormalities can help prevent severe liver damage in patients taking pemoline.

Question 7 of 9

A patient in the ICU develops acute gastrointestinal bleeding (GIB) requiring urgent intervention. What intervention should the healthcare team prioritize to manage the patient's bleeding?

Correct Answer: A

Rationale: The healthcare team should prioritize performing endoscopic hemostasis with mechanical or thermal techniques in a patient with acute gastrointestinal bleeding (GIB) requiring urgent intervention. This approach involves directly visualizing the bleeding site and applying methods such as clipping, coagulation, or band ligation to stop the bleeding. Endoscopic hemostasis is considered the gold standard for managing acute GIB as it allows for both diagnostic and therapeutic intervention in real-time, offering a targeted and effective way to control bleeding and prevent recurrent episodes. Administering proton pump inhibitors (PPIs) may help in reducing gastric acid secretion and promoting ulcer healing but is not the primary intervention for actively bleeding patients. Implementing strict bed rest may be necessary in some cases to minimize physical exertion, but it is not the primary intervention to manage acute GIB. Transfusion of fresh frozen plasma to correct coagulopathy may be necessary if

Question 8 of 9

Upon clinical assessment, the nurse observes that the OUTSTANDING manifestation of the patient is ______.

Correct Answer: D

Rationale: Upon clinical assessment, the nurse observes that the outstanding manifestation of the patient is edema. Edema is characterized by the accumulation of excess fluid in the body's tissues, leading to swelling. Edema can be a sign of various health conditions, such as heart failure, kidney disease, liver disease, or injury. It is crucial to identify and address the underlying cause of edema promptly to prevent complications and provide appropriate treatment for the patient.

Question 9 of 9

Which of the following laboratory findings is characteristic of a patient with a diagnosis of gestational diabetes mellitus (GDM)?

Correct Answer: D

Rationale: The diagnosis of gestational diabetes mellitus (GDM) is typically confirmed through an oral glucose tolerance test (OGTT) during pregnancy. In GDM, the 2-hour plasma glucose level during the OGTT is equal to or greater than 140 mg/dL. This finding is characteristic of GDM and distinguishes it from other types of diabetes. Fasting blood glucose ≥126 mg/dL is diagnostic of diabetes mellitus outside of pregnancy, not specifically GDM. Random plasma glucose ≥200 mg/dL is indicative of uncontrolled diabetes in general. Hemoglobin A1c (HbA1c) ≥6.5% is used for diagnosing diabetes outside of pregnancy and is not specific to GDM.

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