ATI RN
Foundations and Adult Health Nursing Test Bank Questions
Question 1 of 5
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 5
Which of the following nursing actions should the nurse TEACH the patient's care giver regarding tracheostomy care?
Correct Answer: C
Rationale: Cleaning the inner cannula daily helps prevent the accumulation of secretions and debris, which can lead to blockages and infections. It is an essential aspect of tracheostomy care to maintain the patency of the airway and prevent complications. Caregivers should be taught how to safely remove, clean, and reinsert the inner cannula as part of routine tracheostomy care.
Question 3 of 5
Attention deficit, Hyperactivity, disorder (ADHD) is characterized by NOT one of the following?
Correct Answer: A
Rationale: Attention deficit hyperactivity disorder (ADHD) is characterized by inattentiveness, overactivity, and impulsiveness. Individuals with ADHD may have difficulty paying attention, completing tasks, sitting still, or controlling their impulses. Mental retardation (now referred to as intellectual disability) is a separate condition characterized by limitations in intellectual functioning and adaptive behaviors. While individuals with ADHD may experience difficulties in school or work due to their symptoms, ADHD itself does not indicate mental retardation.
Question 4 of 5
The patient with diagnosis of schizophrenia who has been taking Clozapine will inform the patients family that the positive effect of this drug is
Correct Answer: B
Rationale: Clozapine is an atypical antipsychotic medication primarily used in the treatment of schizophrenia. One of the positive effects of Clozapine is the reduction of psychotic symptoms experienced by the patient, such as hallucinations (not hearing loss). Clozapine is effective in managing both positive symptoms (hallucinations, delusions, disorganized thinking) and negative symptoms (apathy, social withdrawal, lack of motivation) of schizophrenia. It is known for its efficacy in reducing hallucinations and other psychotic symptoms, helping the patient to lead a more stable and functional life.
Question 5 of 5
Which assessment by the nurse would cause a concern for Meperidine Overdosed?
Correct Answer: C
Rationale: Meperidine (Demerol) is an opioid analgesic. Overdose of Meperidine can lead to respiratory depression, characterized by slow and shallow breathing. As a result of respiratory depression, hypercapnia, which is an increased level of carbon dioxide in the blood, can occur. This is a serious concern and requires immediate medical intervention to support respiratory function. Therefore, hypercapnia would be the assessment by the nurse that causes a concern for Meperidine overdose.