ATI RN
Foundations and Adult Health Nursing Study Guide Answers Questions
Question 1 of 9
One of the lecturers discussed the complications that patients may have while on IV therapy. Which of the following is the most common Complication that IV patients may contract while on IV therapy?
Correct Answer: B
Rationale: Phlebitis is the most common complication that patients may contract while on IV therapy. Phlebitis is the inflammation of the vein where the IV is inserted, which can cause redness, pain, and swelling along the vein. It can be caused by mechanical irritation, chemical irritation, or infection from the IV catheter. Prompt removal of the IV catheter and appropriate treatment are necessary to manage phlebitis and prevent further complications. While embolism, cardiac overload, and aneurysm are potential complications of IV therapy, phlebitis is more commonly seen in clinical practice.
Question 2 of 9
A risk is any event that causes problems or benefits on the healthcare institution. The Medical Director knows that potential risks must be identified across the hospital in order to prevent the following, EXCEPT
Correct Answer: C
Rationale: Incident reports are a crucial tool for capturing data on adverse events, near misses, and other incidents within a healthcare institution. These reports help in analyzing patterns, identifying areas for improvement, and implementing quality and safety measures. Therefore, incident reports themselves are not something that needs to be prevented; instead, they are a critical part of the risk management process to enhance patient safety and quality of care.
Question 3 of 9
A patient with a history of coronary artery disease is prescribed aspirin for secondary prevention. Which adverse effect is a potential concern with long-term aspirin therapy?
Correct Answer: B
Rationale: Long-term aspirin therapy, especially at higher doses, can increase the risk of gastrointestinal bleeding. Aspirin irreversibly inhibits cyclooxygenase enzyme, which is essential for the production of prostaglandins involved in mucosal protection of the gastrointestinal tract. Without these protective prostaglandins, the stomach lining becomes more susceptible to damage from gastric acid, leading to potential ulcer formation and bleeding. Patients with a history of coronary artery disease may be on aspirin for secondary prevention, and it is crucial to monitor for signs of bleeding such as black, tarry stools or abdominal pain. The benefits of aspirin in preventing cardiovascular events need to be weighed against the risk of adverse effects like gastrointestinal bleeding, especially in patients on long-term therapy.
Question 4 of 9
A woman in active labor is experiencing prolonged rupture of membranes (>24 hours). What complication should the nurse assess for in the mother and fetus?
Correct Answer: A
Rationale: Prolonged rupture of membranes (>24 hours) increases the risk of intrauterine infection for both the mother and the fetus. When the amniotic sac has been ruptured for an extended period, there is a higher likelihood of bacteria entering the uterus, leading to chorioamnionitis (inflammation of the fetal membranes due to infection). Intrauterine infection can be dangerous for both the mother and fetus, potentially causing sepsis, preterm labor, and other complications. Therefore, it is crucial for the nurse to assess for signs and symptoms of infection in both the mother and fetus when managing a woman in active labor with prolonged rupture of membranes.
Question 5 of 9
Which of the following tools used by nurses in the community setting for assessing health needs and problems of families that is similar to family coping index
Correct Answer: D
Rationale: Nursing diagnosis is the tool used by nurses in the community setting for assessing health needs and problems of families that is similar to the family coping index. Nursing diagnosis involves systematic assessment of a patient's health status, analysis of data, and identification of actual or potential health problems. Just like the family coping index, nursing diagnosis helps nurses to identify key issues and develop a plan of care that addresses the specific needs and challenges faced by the family. This process allows nurses to provide individualized care that supports the family in coping with their health needs and improving their overall well-being.
Question 6 of 9
A patient receiving palliative care for end-stage chronic obstructive pulmonary disease (COPD) experiences chronic cough and excessive sputum production. What intervention should the palliative nurse prioritize to address the patient's symptoms?
Correct Answer: B
Rationale: Encouraging the patient to practice controlled coughing techniques would be the most appropriate intervention to address the symptoms of chronic cough and excessive sputum production in a patient with end-stage COPD receiving palliative care. Controlled coughing techniques can help the patient effectively clear respiratory secretions and improve airway clearance without the need for additional medications or interventions. This approach focuses on optimizing the patient's ability to manage their symptoms and maintain comfort, which aligns with the goals of palliative care. Administering bronchodilator medications, prescribing mucolytic medications, or referring the patient to a respiratory therapist for breathing exercises may have limited effectiveness in this advanced stage of the disease, and controlled coughing techniques would be a more practical and patient-centered approach to symptom management.
Question 7 of 9
Twelve hours after vaginal delivery, Nurse Kayla palpates the fundus of a primiparous patient and finds it to be firm, above the umbilicus and deviated to the right. What is the BEST thing for Nurse Kayla to do for the patient?
Correct Answer: C
Rationale: The best thing for Nurse Kayla to do for the patient is to encourage her to ambulate and to void. In this scenario, the fundus being firm, above the umbilicus, and deviated to the right indicates uterine atony with a full bladder. This finding is suggestive of a distended bladder pushing the uterus upwards and to the right. Encouraging the patient to ambulate helps promote uterine contractions, which can aid in the firming up of the uterus. Additionally, emptying the bladder will help the uterus to contract and return to its midline position. This intervention is non-invasive and promotes normal postpartum recovery without the need for medication or excessive manipulation.
Question 8 of 9
Nurse Mary had observedthat most patients with hypertension stop taking their medications and heard them saying "I feel good already" Which is the APPROPRIATE nursing diagnosis?
Correct Answer: D
Rationale: The appropriate nursing diagnosis for this situation is "Ineffective coping" because the patients with hypertension who stop taking their medications despite feeling good may be using this behavior as a maladaptive coping mechanism. It suggests that they might not fully understand the importance of medication adherence or are struggling to accept their diagnosis. By not adhering to their prescribed treatment, they are putting themselves at risk for complications associated with uncontrolled hypertension. Therefore, the nursing diagnosis of "Ineffective coping" addresses the patients' inability to deal with their condition in a healthy manner, leading to noncompliance with their treatment regimen.
Question 9 of 9
Endocrine changes often result in a bulimic patient. Which of the following would be an expected change in Sherry?
Correct Answer: C
Rationale: Endocrine changes in a bulimic patient, such as Sherry, can lead to disruptions in the pituitary gland's function. Hypopituitarism refers to a disorder in which the pituitary gland does not produce one or more of its hormones adequately. This can result in hormonal imbalances and have various effects on the body's functions. In Sherry's case, developing hypopituitarism would be an expected change due to the endocrine disruptions associated with bulimia. It is important for healthcare providers to monitor and address these endocrine changes in bulimic patients to prevent further complications.