ATI RN
Foundations and Adult Health Nursing Test Bank Questions
Question 1 of 5
During the immediate post-operative phase , the PRIMARY goal of the health care team is to maintain ventilation. Which of the following situations should be observed as a result of hypoxemia?
Correct Answer: C
Rationale: One of the main consequences of hypoxemia, which is low oxygen levels in the blood, is decreased oxygen saturation. Oxygen saturation refers to the percentage of hemoglobin molecules in the blood that are bound to oxygen. When there is insufficient oxygen in the blood due to hypoxemia, the oxygen saturation levels will drop. This can lead to symptoms such as shortness of breath, confusion, rapid heart rate, and ultimately can result in tissue damage if not corrected promptly. Monitoring oxygen saturation levels is crucial in the immediate post-operative phase to ensure adequate ventilation and oxygenation for the patient's recovery.
Question 2 of 5
A woman in active labor has been diagnosed with placenta previa. What is the priority nursing intervention?
Correct Answer: A
Rationale: In the case of a woman in active labor with placenta previa, the priority nursing intervention is to prepare for an immediate cesarean section. Placenta previa is a condition in which the placenta covers part or all of the cervix, which can lead to severe bleeding during labor and delivery. The risk of hemorrhage is significant, making a cesarean section the safest option for both the mother and the baby in this situation. It is crucial to act promptly to prevent complications and ensure the well-being of both the mother and the baby. Administering intravenous oxytocin to augment labor or inserting a Foley catheter to monitor urine output would not address the immediate risk of hemorrhage associated with placenta previa. Implementing bed rest and continuous fetal monitoring may be part of the overall care plan but not the priority intervention in this urgent situation.
Question 3 of 5
A patient presents with gradual, painless visual field loss in both eyes, particularly in the peripheral vision. Tonometry reveals elevated intraocular pressure (IOP). Which of the following conditions is most likely responsible for this presentation?
Correct Answer: A
Rationale: The patient presents with gradual, painless visual field loss in both eyes, particularly in the peripheral vision, which is characteristic of glaucoma. The elevated intraocular pressure (IOP) on tonometry further supports a diagnosis of glaucoma. Open-angle glaucoma is the most common type of glaucoma and typically presents insidiously with a slow progression of vision loss. In open-angle glaucoma, the drainage angle of the eye remains open but becomes less efficient over time, leading to increased intraocular pressure and optic nerve damage. This results in peripheral visual field loss. Closed-angle glaucoma, on the other hand, presents more acutely with sudden eye pain, redness, and blurred vision due to a sudden increase in intraocular pressure from a blocked drainage angle. Age-related macular degeneration and diabetic retinopathy typically do not present with elevated IOP or peripheral visual field loss.
Question 4 of 5
One GOOD nursing intervention of the nurse for Almira would be to do which of the following?
Correct Answer: A
Rationale: The correct nursing intervention for Almira would be to advise her to eat her meals. This is important in promoting her health and well-being, especially if she has been neglecting her own nutrition due to stress or caring for her son, Jay. Providing proper nutrition is a basic aspect of nursing care that supports the overall health and recovery of the patient. By encouraging Almira to prioritize her own nutrition, the nurse can help ensure that she has the physical strength and energy needed to take care of herself and her son effectively.
Question 5 of 5
A patient with a severe bacterial infection has elevated levels of C-reactive protein (CRP) in their blood. Which of the following functions does CRP primarily serve during the acute phase response?
Correct Answer: B
Rationale: During the acute phase response, C-reactive protein (CRP) primarily serves to activate the complement system. CRP binds to phosphocholine on the surface of pathogens, allowing for the activation of the classical pathway of the complement system. This leads to the recruitment of immune cells, opsonization of pathogens, and enhancement of phagocytosis. The activation of the complement system by CRP plays a crucial role in the host defense against infections, aiding in the elimination of pathogens and the resolution of inflammation.
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