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?

Questions 165

ATI RN

ATI RN Test Bank

Adult Health Nursing Test Banks Questions

Question 1 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 2 of 9

A postpartum client who is breastfeeding expresses concerns about breast engorgement and discomfort. What nursing intervention should be prioritized to alleviate symptoms?

Correct Answer: A

Rationale: The most appropriate nursing intervention to alleviate breast engorgement and discomfort in a breastfeeding client is to encourage frequent breastfeeding or pumping sessions. Engorgement occurs when the breasts become overly full of milk, causing them to become swollen, firm, and painful. By ensuring that the baby breastfeeds frequently, the client can effectively empty the breasts, which helps to relieve engorgement and discomfort. Encouraging the client to breastfeed on demand and ensuring proper latching can help prevent further engorgement issues. Pumping can also be useful if the baby is unable to feed directly from the breast or to relieve engorgement between feedings. This intervention addresses the root cause of the problem and promotes the client's comfort and breastfeeding success. Applying cold packs, using a supportive bra or breast binder, and administering oral analgesics may provide some relief for discomfort but do not address the underlying issue of engorgement.

Question 3 of 9

A patient in the ICU develops catheter-related bloodstream infection (CRBSI) associated with a central venous catheter. What intervention should the healthcare team prioritize to manage the patient's infection?

Correct Answer: A

Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.

Question 4 of 9

An EMT approaches an accident victim. The victim says, "Don't touch me!" The EMT says, you need help, but the victim replies NO! don't touch me. If the EMT takes the victim by the arm and forces the victim into the ambulance, the EMT could be guilty of:

Correct Answer: A

Rationale: Battery refers to the intentional and offensive physical contact with another person without their consent, resulting in harm or injury. In this scenario, the victim clearly expressed their unwillingness to be touched or helped by saying, "Don't touch me!" multiple times. By ignoring the victim's refusal and physically forcing them into the ambulance, the EMT is committing battery even though they may have had good intentions to provide assistance. It is important for medical professionals, including EMTs, to always respect a person's right to refuse medical treatment or assistance, even in emergency situations.

Question 5 of 9

According to RA 9482 or the anti- Rabies Act of 2007, which of the following statement s regarding rabies post exposure prophylaxis is APPLICABLE?

Correct Answer: A

Rationale: According to RA 9482 or the Anti-Rabies Act of 2007, one of the key components of rabies prevention is to have dogs regularly vaccinated against rabies. This is a crucial step in reducing the risk of rabies transmission from dogs to humans. By ensuring that dogs are vaccinated, the likelihood of rabies exposure is significantly decreased. Additionally, proper vaccination also helps protect the health and well-being of the dogs themselves. Therefore, ensuring regular vaccination of dogs is an applicable and important statement regarding rabies post-exposure prophylaxis as mandated by the law.

Question 6 of 9

A postpartum client presents with signs of urinary retention, including suprapubic discomfort and inability to void. Which nursing intervention should be implemented first?

Correct Answer: B

Rationale: Assisting the client to a seated position on the toilet should be implemented first. This position promotes relaxation of the pelvic floor muscles and can help facilitate urinary elimination. It is a non-invasive and least intrusive intervention compared to performing intermittent catheterization or administering diuretic medication. Encouraging the client to drink plenty of fluids is important for promoting overall urinary function, but in this case, the priority is to aid the client in attempting to void first.

Question 7 of 9

In order to determine the patient's ability to concentrate and focus, which would be the PRIORITY nursing action?

Correct Answer: C

Rationale: Assessing the mental status of the patient is the PRIORITY nursing action to determine the patient's ability to concentrate and focus. This assessment includes evaluating the patient's level of alertness, orientation, memory, thought processes, and mood. By observing the patient's mental status, the nurse can gain valuable information about the patient's cognitive function, attention span, and ability to concentrate. This assessment will help guide further interventions and care planning for the patient. Asking for academic performance or conducting paper and pencil tests may be useful tools to assess concentration and focus, but they should come after a comprehensive evaluation of the patient's mental status. Referring the patient to a psychiatrist may be necessary based on the assessment findings, but it should not be the first step in determining the patient's ability to concentrate and focus.

Question 8 of 9

A patient presents with a well-demarcated, hyperpigmented patch with irregular borders and asymmetric color distribution on the face. The lesion has increased in size over the past few months. Which of the following conditions is most concerning for this presentation?

Correct Answer: D

Rationale: The presentation described, including a well-demarcated, hyperpigmented patch with irregular borders, asymmetric color distribution, and increase in size over a short period, is concerning for melanoma. Melanoma is a type of skin cancer that arises from melanocytes, the cells that produce pigment in the skin. The irregular borders, color variation, and growth over time are classic signs of melanoma. Melanomas are potentially dangerous and should be evaluated promptly by a healthcare provider for proper diagnosis and treatment. It is important to distinguish melanoma from other benign lesions like melanocytic nevus (mole), lentigo simplex, and seborrheic keratosis, as early detection and treatment of melanoma can significantly impact patient outcomes.

Question 9 of 9

A patient presents with central obesity, moon face, buffalo hump, and purple striae. Laboratory tests reveal elevated cortisol levels. Which endocrine disorder is most likely responsible for these symptoms?

Correct Answer: D

Rationale: The patient's presentation of central obesity, moon face, buffalo hump, purple striae, and elevated cortisol levels strongly suggest Cushing's syndrome. Cushing's syndrome is a disorder characterized by excessive levels of cortisol, either due to an endogenous (e.g., adrenal tumor) or exogenous (e.g., prolonged steroid use) source. The classic physical features of Cushing's syndrome include central obesity with thin extremities (truncal obesity), moon face (rounding and reddening of the face), buffalo hump (accumulation of fat between the shoulders), and purple striae (stretch marks that are wide and purple in color). In the context of the elevated cortisol levels, these clinical signs are highly indicative of Cushing's syndrome. Hyperthyroidism, hypothyroidism, and diabetes mellitus would not typically present with the specific combination of symptoms described.

Access More Questions!

ATI RN Basic


$89/ 30 days

ATI RN Premium


$150/ 90 days