ATI RN
Adult Health Nursing Answer Key Questions
Question 1 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 2 of 5
A retired nurse stops to help in an emergency at the scene of an accident, if the injured party files suit and the, the nurse would probably be covered by
Correct Answer: D
Rationale: The Good Samaritan Law offers legal protection to individuals who voluntarily provide assistance at the scene of an emergency or accident. These laws vary by state, but generally, they grant immunity from civil liability for the individual providing aid as long as they act in good faith and without expectation of compensation. In this case, the retired nurse who stopped to help in the emergency at the scene of an accident would likely be covered by the Good Samaritan Law, protecting her from being sued by the injured party for any unintended consequences of her efforts to assist.
Question 3 of 5
The inappropriate use of restraints or seclusion is considered which form of intentional tort?
Correct Answer: A
Rationale: The inappropriate use of restraints or seclusion is considered a form of false imprisonment, which is an intentional tort. False imprisonment occurs when someone intentionally restricts another person's freedom of movement without their consent or legal justification. In healthcare settings, using restraints or seclusion inappropriately on a patient can constitute false imprisonment if it is not done for the safety of the patient or others and without proper authorization. This act can lead to legal consequences and liabilities for healthcare providers.
Question 4 of 5
Which of the following substances has abnormal values EARLY in the course of multiple myeloma (MM)?
Correct Answer: C
Rationale: In the early stages of multiple myeloma (MM), abnormal values are often seen in the levels of immunoglobulins. This is due to the abnormal proliferation of plasma cells in the bone marrow, leading to overproduction of monoclonal immunoglobulins (M proteins). These abnormal immunoglobulins can be detected in blood tests and are a key diagnostic feature of MM. Changes in red blood cells, white blood cells, and platelets are not typically early indicators of multiple myeloma.
Question 5 of 5
A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?
Correct Answer: B
Rationale: The client should be assisted to lie in bed on the unaffected side for a thoracentesis procedure. This position allows for better access to the pleural space for the insertion of a needle to aspirate the fluid or air. Gravity helps to separate the fluid or air, making it closer to the chest wall for easier removal. Additionally, this position reduces the risk of injury to the lung or other structures, as the needle is directed away from these vital structures. Lying on the unaffected side also helps in preventing potential complications and ensures the safety and effectiveness of the procedure.