ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 5
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 2 of 5
After instructing a primiparous patient about episiotomy care, which of the following indicates successful teaching?
Correct Answer: A
Rationale: Wiping the episiotomy area from front to back using a blotting motion helps prevent introducing bacteria from the rectal area to the vaginal area, reducing the risk of infection. This technique also avoids causing unnecessary trauma to the healing tissues. Ensuring proper hygiene is vital to prevent complications such as infection, which is crucial for the healing process after an episiotomy.
Question 3 of 5
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.
Question 4 of 5
In order to PREVENT the spread of Scabies infestation to other residents in the community, Nurse Emma should teach the family, which of the following?
Correct Answer: B
Rationale: The correct answer is to avoid sharing items used by the infected person in order to prevent the spread of Scabies infestation to other residents in the community. Scabies is a highly contagious skin infestation caused by the Sarcoptes scabiei mite, and it can easily spread through direct skin-to-skin contact or by sharing personal items such as clothing, towels, and bedding. By advising the family to avoid sharing items used by the infected person, Nurse Emma is helping to prevent the transmission of the mites to others in the community. Boiling utensils, taking excessive baths, or wearing masks and shields are not necessary preventive measures for scabies infestation.
Question 5 of 5
A patient admitted to the ICU develops acute exacerbation of chronic heart failure (CHF) with pulmonary edema and respiratory distress. What intervention should the healthcare team prioritize to manage the patient's exacerbation?
Correct Answer: B
Rationale: In this scenario, the patient is presenting with acute exacerbation of chronic heart failure (CHF) complicated by pulmonary edema and respiratory distress. The priority intervention for managing this exacerbation is to initiate positive pressure ventilation for respiratory support. Positive pressure ventilation, such as non-invasive positive pressure ventilation (NIPPV) or invasive mechanical ventilation, can help improve oxygenation and decrease the work of breathing for the patient. By providing adequate respiratory support, ventilation can reduce the negative effects of pulmonary edema and respiratory distress due to CHF exacerbation. Administering intravenous loop diuretics (Choice A) might be necessary to address fluid overload, but it is not the initial priority as ensuring adequate ventilation is crucial. Emergent pericardiocentesis (Choice C) is not indicated in this scenario as there is no mention of cardiac tamponade. Inotropic medications (Choice D) may be considered in managing acute exacerbation of CHF but
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