Questions 9

ATI RN

ATI RN Test Bank

Adult Health Nursing Answer Key Questions

Question 1 of 5

The female client who is very anxious and fidgety is blowing off to much carbon dioxide develops tingling sensation of the lips and fingers and is not able to control her respirations. The MOST appropriate nursing intervention for this client is to _____.

Correct Answer: C

Rationale: The client is experiencing symptoms of hyperventilation, a condition that occurs when there is excessive elimination of carbon dioxide from the body. Breathing into a paper bag can help by allowing the client to rebreathe carbon dioxide, which can help restore the balance of gases in the blood and alleviate the tingling sensations in the lips and fingers. This technique is commonly used to help regulate breathing in cases of hyperventilation. Administering oxygen (choice B) may not be necessary as the issue lies with an imbalance of carbon dioxide, not a lack of oxygen. Instructing the client to blow her nose and take deep breaths (choice A) may not address the underlying problem effectively. Administering IV fluids (choice D) is not relevant to the client's symptoms of hyperventilation.

Question 2 of 5

The patient 's wife is-so anxious about the condition of her husband. The MOST appropriate INITIAL intervention for the nurse to make is to ________.

Correct Answer: C

Rationale: In situations where a patient's family member is expressing anxiety about their loved one's condition, it is important for the nurse to provide clear and accurate information about the patient's status. By explaining the nature of the injury and reassuring the wife that her husband's condition is stable, the nurse can help alleviate her anxiety and address her concerns in a meaningful way. This intervention focuses on open communication and providing emotional support, which are crucial in helping the family member cope with the situation. It is essential to establish trust and create a supportive environment for the family member during this stressful time.

Question 3 of 5

A patient with a tibial shaft fracture undergoes surgical fixation with an intramedullary nail. What postoperative complication should the healthcare team monitor for in the immediate postoperative period?

Correct Answer: C

Rationale: Following surgical fixation of a tibial shaft fracture with an intramedullary nail, healthcare providers should monitor for the development of fat embolism syndrome (FES) in the immediate postoperative period. FES is a serious complication that occurs when fat droplets from the bone marrow enter the bloodstream and cause respiratory and neurological symptoms. Clinical manifestations of FES may include dyspnea, tachypnea, petechial rash, altered mental status, and hypoxemia. Prompt recognition and treatment are essential in managing fat embolism syndrome to prevent serious complications such as respiratory failure and neurological deficits. Monitoring for signs and symptoms of FES is crucial in the postoperative care of patients undergoing surgical fixation of long bone fractures.

Question 4 of 5

The nurse is conducting an assessment to her patient who has edema of the lower extremities due to congestive heart failure. If edema is graded on a scale of +1 (no visible edema in the leg) to 4+ (leg very swollen), what will the Nurse document in her chart if her assessment findings of the edema is SLIGHTLY swollen?

Correct Answer: B

Rationale: In the grading system used for edema, +1 indicates no visible edema in the leg, +2 indicates slight edema with indentations that quickly resolve, +3 indicates moderate edema with deeper indentations that may take longer to resolve, and +4 indicates severe edema with very swollen legs. In this case, since the edema is described as slightly swollen, the appropriate grade to document would be +2.

Question 5 of 5

In the assessing the health condition of the preganant patient, Nurse Vera should focus on the _________.

Correct Answer: A

Rationale: Nurse Vera should focus on the last menstrual period when assessing the health condition of the pregnant patient because it is crucial for determining the estimated due date of the pregnancy. Knowing the date of the last menstrual period allows healthcare providers to calculate the gestational age of the fetus, monitor the progress of the pregnancy, and identify any potential issues or complications that may arise. Additionally, the last menstrual period is necessary for accurate dating of the pregnancy and scheduling prenatal care visits and screenings. By focusing on the last menstrual period, Nurse Vera can gather important information that will guide the management and care of the pregnant patient.

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