ATI RN
Foundations and Adult Health Nursing Test Bank Questions
Question 1 of 9
To ensure quality nursing care to a patient in skin traction, what is the PRIORTTY intervention that a nurse has to assess frequently?
Correct Answer: B
Rationale: When a patient is in skin traction, the constant pressure and rubbing against the skin from the traction device can lead to skin breakdown. Therefore, assessing for signs of skin breakdown, such as redness, irritation, or pressure injuries, is crucial to prevent complications and ensure the patient's comfort and safety. Prompt identification and intervention for any skin issues can prevent further damage and promote healing, making this the priority intervention for quality nursing care in skin traction. While monitoring for signs of infection, urinary incontinence, and bowel sounds are important, skin breakdown poses a more immediate threat to the patient's well-being in this scenario.
Question 2 of 9
The first standard step in oxygen therapy that the nurse should do is________.
Correct Answer: A
Rationale: The first standard step in oxygen therapy that the nurse should do is to assess the client's condition. Before initiating any oxygen treatment, it is essential to assess the client's respiratory status, oxygen saturation levels, vital signs, and overall condition. This initial assessment helps the nurse to determine the appropriate course of oxygen therapy based on the client's individual needs and current health status. Assessing the client's condition first ensures that the oxygen therapy provided is safe and effective for the specific needs of the client.
Question 3 of 9
Charting are important documents that are used in court proceedings a Nurse Chona should take note that the following entry recorded would be MOST defensible in court?
Correct Answer: A
Rationale: Of the options provided, documenting objective, observable findings such as large bruises on the thigh upon assessment is the most defensible entry in court. This type of entry is based on the nurse's direct observation and assessment of the patient's physical condition, which can be corroborated by other healthcare providers or evidence. It provides clear, factual information without making assumptions or subjective judgments. In court, this type of documentation can help support the nurse's credibility and reliability as a witness.
Question 4 of 9
A patient presents with chest pain that occurs during heavy lifting or physical exertion and is relieved by rest. An electrocardiogram (ECG) may show transient ST-segment depression. Which cardiovascular disorder is most likely responsible for these symptoms?
Correct Answer: A
Rationale: The given patient's symptoms of chest pain that occurs during heavy lifting or physical exertion and is relieved by rest are consistent with stable angina. Stable angina is characterized by predictable chest pain that occurs with exertion and is typically relieved by rest or nitroglycerin. The transient ST-segment depression on ECG is also a common finding in patients with stable angina, which reflects myocardial ischemia during episodes of chest pain triggered by exertion. In contrast, unstable angina is characterized by chest pain at rest or with minimal exertion that is of increasing frequency, severity, or duration. Acute myocardial infarction is associated with persistent ST-segment elevation or new Q-waves on ECG, and Prinzmetal's angina is characterized by chest pain at rest due to coronary artery spasm rather than exertion.
Question 5 of 9
A woman in active labor experiences irregular and ineffective uterine contractions, resulting in prolonged cervical dilation. What nursing intervention should be implemented to address this abnormal labor pattern?
Correct Answer: A
Rationale: A woman experiencing irregular and ineffective uterine contractions with prolonged cervical dilation may indicate labor dystocia, also known as abnormal labor progression. To address this issue, the nursing intervention that should be implemented is to encourage the mother to ambulate and change positions frequently. This can help optimize fetal positioning and encourage descent through the birth canal by using gravity to aid in the progression of labor. Changing positions can also potentially improve the quality and effectiveness of contractions, leading to more successful cervical dilation and labor progress. Encouraging ambulation and position changes are non-invasive, patient-centered interventions that can be helpful in managing labor dystocia before considering more invasive interventions like cesarean section.
Question 6 of 9
As a nurse, which of the following are the critical factors for successful integration of loss during the grieving process?
Correct Answer: B
Rationale: Accurate assessment and intervention by the nurse or helping person are critical factors for successful integration of loss during the grieving process. This involves the nurse's ability to assess the patient's grieving process effectively, identify their needs, provide appropriate support, and intervene when necessary. By utilizing proper assessment techniques and offering timely interventions, the nurse helps facilitate the patient's journey through the grieving process, promoting healthy coping mechanisms and ultimately assisting in achieving successful integration of their loss. Trustworthiness and a healthy attitude about grief are important qualities for a nurse, but without accurate assessment and intervention, the grieving process may not progress smoothly.
Question 7 of 9
The incoming nurse on duty reported, the nurse is administering a medication, the patient says, "This pill looks different from the one I had taken before. " What is the APPROPRIATE action of the nurse?
Correct Answer: C
Rationale: When a patient expresses concern about a medication looking different from what they had taken before, it is crucial for the nurse to verify the original prescription to ensure that the correct medication is being administered. Checking the original medication prescription will help the nurse confirm if there have been any changes or errors in the medication orders. This step is essential for patient safety and to prevent any potential medication errors. It is important to prioritize patient safety and well-being in such situations, and verifying the prescription is the appropriate action to take in this case.
Question 8 of 9
Nurse Maris is correct in identifying whinch of the following is a health resource problem?
Correct Answer: C
Rationale: The correct answer, C, reflects a health resource problem. The absence of a midwife in the community means that there is a lack of a critical health resource necessary for providing essential health services, especially for pregnant women and infants. This directly impacts the access to healthcare services and can contribute to negative health outcomes, such as high maternal mortality rates. The other options do not directly address a health resource problem but rather focus on specific issues or conflicts within the community.
Question 9 of 9
Which procedure has to be done to the patient to establish a definitive diagnosis of lung cancer?
Correct Answer: C
Rationale: Bronchoscopy is a procedure that allows direct visualization of the inside of the airways in the lungs. It is considered the most definitive method to establish a diagnosis of lung cancer as it can directly visualize any abnormal growths or tumors in the bronchial tubes. During bronchoscopy, tissue samples can be collected for biopsy to confirm the presence of cancer cells. This procedure is more accurate compared to other diagnostic methods such as chest x-ray, CT scan, cytological study of sputum, or magnetic resonance imaging in confirming a diagnosis of lung cancer.