ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 9
Patient Josephine was referred to the physician, routine blood examinations were taken. After reviewing the serum electrolyte. levels an order of isotonic intravenous (IV) infusion was prescribed. Which IV solution should the nurse prepare?
Correct Answer: B
Rationale: The order for isotonic intravenous (IV) infusion indicates that the IV solution should have an osmolarity similar to that of blood serum, which is approximately 0.9 percent sodium chloride solution (normal saline). In the given choices, the closest option to isotonic solution is the 0.45 percent sodium chloride solution. This solution is hypotonic compared to blood serum, making it a suitable choice for isotonic IV infusion to prevent fluid shifts and maintain electrolyte balance in the patient. The other options, such as 5 percent dextrose in water (hypotonic), 10 percent dextrose in water (hypertonic), and 3 percent sodium chloride solution (hypertonic), do not match the requirement for an isotonic IV solution in this case.
Question 2 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 3 of 9
When conducting a nursing history on the Health Perception, Health Management pattern of functioning what is the APPROPRIATE question to be asked pre-operatively?
Correct Answer: C
Rationale: When conducting a nursing history on the Health Perception, Health Management pattern of functioning pre-operatively, an appropriate question to ask would be "Are you aware of risk factors for your disease?" This question helps assess the individual's level of awareness and understanding of their health condition and the factors that may impact it. Understanding the patient's knowledge of their risk factors can help guide interventions and education before surgery to optimize their health outcomes. Asking about perceived wound healing, shortness of breath, or weight changes may not be directly related to the patient's awareness of their disease risk factors in the pre-operative setting.
Question 4 of 9
When the patient was informed about induction, she asks Nurse Aurora what it is all about. which of the following statement by the nurse is correct? Induction is a
Correct Answer: B
Rationale: Induction is the deliberate initiation of uterine contractions that stimulates labor. It is usually initiated when natural labor is not progressing or is overdue. This process can involve the use of medications or other methods to help the uterus contract and initiate labor. Option B accurately describes induction, making it the correct answer in this case.
Question 5 of 9
The applicant was further asked about an incident report. Which of the following is a PRIORITY Case for an incident report be accomplished?
Correct Answer: A
Rationale: A patient falling from the bed is a critical incident that must be prioritized for an incident report. Patient falls can lead to injuries, complications, or even serious consequences. Documenting this incident is crucial for analyzing the cause of the fall, implementing prevention measures, and ensuring patient safety. Additionally, reporting patient falls is a standard practice in healthcare settings to maintain transparency and accountability in patient care.
Question 6 of 9
Before the education plan of the staff nurse can be finalized and implemented, it is best that it is reviewed by the
Correct Answer: A
Rationale: Before finalizing and implementing the education plan for the staff nurse, it is important to have the plan reviewed by the nurse supervisor. The nurse supervisor is directly responsible for overseeing the staff nurses and their education and training needs. They have a good understanding of the staff nurse's current skills, areas for improvement, and training requirements. By involving the nurse supervisor in the review process, you can ensure that the education plan is aligned with the overall goals and needs of the nursing staff and the department. Additionally, the nurse supervisor can provide valuable input and insights to help tailor the education plan to meet the specific needs of the staff nurses under their supervision.
Question 7 of 9
A patient presents with symptoms of polyuria, polydipsia, and polyphagia. Laboratory tests reveal hyperglycemia and glycosuria. Which type of diabetes mellitus is the patient most likely experiencing?
Correct Answer: A
Rationale: The patient is most likely experiencing Type 1 diabetes mellitus based on the presentation of polyuria, polydipsia, polyphagia, hyperglycemia, and glycosuria. Type 1 diabetes is characterized by autoimmune destruction of the beta cells in the pancreas, leading to absolute insulin deficiency. This results in high blood sugar levels (hyperglycemia) and glucose spilling into the urine (glycosuria). Patients with Type 1 diabetes often present with the classic symptoms of polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger) due to the body's inability to utilize glucose for energy effectively. Management of Type 1 diabetes typically involves lifelong insulin therapy to maintain blood sugar levels within a target range.
Question 8 of 9
The nurse did an admission procedure. The best position to be assumed by Roy is _____.
Correct Answer: B
Rationale: The best position for a patient to assume during an admission procedure, particularly for respiratory assessment, is the semi-fowler position at least 30 degrees. In the semi-fowler position, the patient's head and upper body are elevated to a 30-degree angle. This position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and enhancing chest expansion. It also facilitates breathing and allows for better assessment of respiratory status. Additionally, the semi-fowler position helps prevent aspiration and promotes comfort and relaxation for the patient during the admission procedure.
Question 9 of 9
A few days later, the patient comes into the emergency department via ambulance stretcher and reveals a work-up of blood sugar level at 800mg/dl, ketones are absent in the urine, she is dehydrated, and has an altered mental status. Based on the data, t he patient is most likely suferring from what specifi medical condition?
Correct Answer: A
Rationale: The patient's presentation with a blood sugar level of 800mg/dL, absence of ketones in the urine, dehydration, and altered mental status points towards Hyperosmolar nonketotic coma (HNKC). HNKC typically occurs in patients with Type 2 diabetes and is characterized by extremely high blood glucose levels (hyperglycemia) without significant ketosis. The absence of ketones in the urine distinguishes HNKC from Diabetic ketoacidosis (DKA). Patients with HNKC often present with severe dehydration, altered mental status, and hyperosmolarity. It is crucial to address the underlying cause of the hyperglycemia, correct dehydration, and normalize blood glucose levels promptly in the management of HNKC.