ATI RN
Adult Health Nursing Test Bank Questions
Question 1 of 9
The physician inserted a chest tube drainage to Mr. Alda in order to help re-expand the lungs. Which of the following should you prepare FIRST as a nurse in case of emergency when the tube is accidentally disconnected?
Correct Answer: A
Rationale: Correct Answer: A - sterile clamps Rationale: 1. **Immediate action**: Sterile clamps are essential to clamp the chest tube to prevent air from entering the pleural space. 2. **Prevent lung collapse**: Clamping the tube will prevent lung collapse and maintain positive pressure in the pleural space. 3. **Buy time**: By clamping the tube, you buy time to properly reattach the tube or secure it with a new connection. 4. **Safety**: Sterile clamps are a quick and effective solution to prevent a potentially life-threatening situation. Summary of other choices: B: Sterile dressing - Not the first priority as the immediate concern is preventing air from entering the pleural space. C: Another chest tube - Not necessary initially as clamping can buy time to reattach the disconnected tube. D: A bottle of sterile water - Not needed for emergency management of a disconnected chest tube.
Question 2 of 9
A 20-year-old woman presents with sudden onset of severe lower abdominal pain and missed menstrual periods for the past two months. She has a positive urine pregnancy test. On transvaginal ultrasound, an empty uterus is visualized, and there is fluid in the cul-de-sac. Which condition is most likely to be responsible for these findings?
Correct Answer: B
Rationale: The correct answer is B: Ectopic pregnancy. In this scenario, the combination of missed periods, positive pregnancy test, and empty uterus on ultrasound with fluid in the cul-de-sac is highly suggestive of an ectopic pregnancy. Ectopic pregnancy occurs when the fertilized egg implants outside the uterus, commonly in the fallopian tube. The presence of fluid in the cul-de-sac indicates possible blood from a ruptured ectopic pregnancy, causing the severe lower abdominal pain. Ovarian cyst rupture (A) typically presents with less severe pain. Septic abortion (C) would present with signs of infection and products of conception in the uterus. Ovarian torsion (D) would present with acute onset of unilateral lower abdominal pain and a palpable adnexal mass, not fluid in the cul-de-sac.
Question 3 of 9
Select the medication that should be discussed by the nurse with the attending physician before administering it to patient with acute angle closure glaucoma
Correct Answer: D
Rationale: The correct answer is D: Atropine. Atropine is a mydriatic agent that can exacerbate acute angle closure glaucoma by dilating the pupil and potentially worsening the condition. The nurse should discuss with the attending physician before administering it to avoid worsening the patient's condition. A: Isopto carpine eye drops are actually used in the treatment of acute angle closure glaucoma as they help in lowering intraocular pressure, so there is no need to discuss this with the physician. B: Mannitol is used as an osmotic diuretic to reduce intraocular pressure in acute angle closure glaucoma, and it does not directly affect the pupil, so it does not require discussion with the physician before administration. C: Corticosporin ophthalmic is a combination of an antibiotic and a corticosteroid used to treat eye infections and inflammation, but it does not have a direct effect on worsening acute angle closure glaucoma, so it does
Question 4 of 9
A patient presents with excessive thirst, large volumes of dilute urine, and low urine osmolality. Laboratory tests reveal hypernatremia and elevated serum osmolality. Which endocrine disorder is most likely responsible for these symptoms?
Correct Answer: D
Rationale: The correct answer is D: Diabetes insipidus. This condition is characterized by excessive thirst, large volumes of dilute urine, low urine osmolality, hypernatremia, and elevated serum osmolality. The underlying cause is a deficiency in or insensitivity to antidiuretic hormone (ADH), leading to the inability of the kidneys to concentrate urine properly. Hyperthyroidism (choice A) and hypothyroidism (choice B) do not directly affect urine concentration. While diabetes mellitus (choice C) can also present with polyuria and polydipsia, it would typically have high urine osmolality due to the presence of glucose. Therefore, diabetes insipidus is the most likely endocrine disorder responsible for these specific symptoms.
Question 5 of 9
Upon entry of the patient to ER, the nurse must FIRST perform which nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Cleanse the bite with soap and running water. This is the first nursing intervention because it is crucial to prevent infection. Cleaning the bite area helps remove bacteria and debris, reducing the risk of infection. Injecting with rabies immune globulin (choice A) and rabies vaccine (choice C) should be done later as per protocol after assessing the situation. Administering pain reliever (choice D) is important but not the first priority in this scenario.
Question 6 of 9
A patient with a history of congestive heart failure is prescribed furosemide. Which electrolyte imbalance is the patient at risk for developing with furosemide therapy?
Correct Answer: B
Rationale: Step 1: Furosemide is a loop diuretic that works in the ascending loop of Henle to inhibit sodium and chloride reabsorption. Step 2: Inhibition of sodium reabsorption leads to increased water and electrolyte excretion, including potassium. Step 3: Increased potassium excretion can lead to hypokalemia, which is a common side effect of loop diuretics like furosemide. Step 4: Hypokalemia can be dangerous, especially in patients with congestive heart failure, as it can worsen cardiac function and lead to arrhythmias. Step 5: Therefore, patients with a history of congestive heart failure prescribed furosemide are at risk for developing hypokalemia due to increased potassium excretion.
Question 7 of 9
The nurse specialist explains that chemotherapyis extremely toxic to the bone marrow and the patient may develop thrombocytopenia. What is the priority goal of the nurse? To take precautions to control _______.
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Chemotherapy can lead to low platelet counts (thrombocytopenia), increasing the risk of bleeding. The priority goal of the nurse is to prevent bleeding by taking precautions such as avoiding invasive procedures, using soft toothbrushes, and monitoring for signs of bleeding. Infection (B) is important but not the priority as bleeding can be life-threatening. Hypotension (C) is not directly related to thrombocytopenia. Diarrhea (D) is a potential side effect of chemotherapy but is not the priority when considering thrombocytopenia.
Question 8 of 9
During surgery, the nurse observes a sudden change in the patient's level of consciousness. What is the nurse's immediate action?
Correct Answer: D
Rationale: The correct immediate action for the nurse is to notify the anesthesia provider immediately (Option D). This is crucial because a sudden change in the patient's level of consciousness during surgery could indicate a serious issue related to anesthesia administration. Notifying the anesthesia provider promptly allows for quick assessment and intervention to address the underlying cause, potentially preventing complications or even saving the patient's life. Administering a reversal agent (Option A) without proper evaluation by the anesthesia provider could be dangerous. Documenting the change in the patient's chart (Option B) is important but not the most immediate action. Checking the patient's vital signs (Option C) is also important but may not provide immediate insight into the cause of the change in consciousness.
Question 9 of 9
A patient presents with redness, pain, and photophobia in the left eye. Slit-lamp examination reveals ciliary injection, corneal edema, and a mid-dilated pupil with fixed reaction to light. Which of the following conditions is most likely responsible for this presentation?
Correct Answer: A
Rationale: The correct answer is A: Anterior uveitis. This condition presents with redness, pain, and photophobia due to inflammation of the uveal tract. Ciliary injection, corneal edema, and mid-dilated pupil with fixed reaction to light are classic signs of anterior uveitis. The other choices can be ruled out based on specific findings: B: Acute angle-closure glaucoma would present with a high intraocular pressure, not fixed dilated pupil. C: Endophthalmitis typically presents with severe pain, hypopyon, and vitreous inflammation. D: Corneal abrasion would not cause ciliary injection or fixed dilated pupil.