ATI RN
Adult Health Nursing Test Banks Questions
Question 1 of 9
Which of the following interventions is most appropriate for a patient with a tension pneumothorax?
Correct Answer: A
Rationale: A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, causing increased pressure in the chest cavity. This can lead to compression of the lung and major blood vessels, leading to inadequate oxygenation and circulation.
Question 2 of 9
What is the BEST urine sample to be used for an accurate result of pregnancy test done at home?
Correct Answer: B
Rationale: First-voided morning urine is the best urine sample to be used for an accurate result of a pregnancy test done at home because it is more concentrated compared to urine samples collected at other times of the day. Overnight, the hCG hormone (human chorionic gonadotropin) builds up in a woman's body, making the early morning urine more likely to contain higher levels of hCG if a woman is pregnant. The concentrated nature of first-morning urine reduces the chances of false-negative results since it provides a higher concentration of the hormone that the test is designed to detect. Therefore, using first-morning urine increases the sensitivity of the pregnancy test and improves the accuracy of the results.
Question 3 of 9
Healthy physical development is dependent upon nutrition, brain development, muscle and bone. Which of the following is NOT APPROPRIATE for physical development of a pre schooler?
Correct Answer: A
Rationale: For a preschooler, it is recommended that they get more than 8 hours of sleep each day. Adequate sleep is crucial for their physical development, overall health, and cognitive function. Preschoolers typically need around 10-13 hours of sleep per day to support their growth and development. Getting less than the recommended amount of sleep can lead to issues such as behavioral problems, difficulty concentrating, and poor physical development. Therefore, ensuring that a preschooler gets enough sleep is vital for their physical well-being.
Question 4 of 9
During the normal postpartum course, when would the nurse expect to note the fundal assessment that will be in line with the umbilicus?
Correct Answer: D
Rationale: After childbirth, the uterus undergoes involution, which is the process of returning to its pre-pregnant size and location. Initially, the fundus is firm and located at or just below the level of the umbilicus immediately after delivery. Over the next 24 hours, the fundus should gradually decrease in height as involution progresses. By the day after delivery, the nurse would expect the fundal assessment to be in line with the umbilicus or slightly below it, indicating normal involution of the uterus. If the fundus remains high or deviates from this expected progression, further assessment and intervention may be needed to prevent complications such as postpartum hemorrhage.
Question 5 of 9
A patient becomes emotional while discussing their recent diagnosis. What is the nurse's most appropriate response?
Correct Answer: B
Rationale: Acknowledging the patient's emotions and offering empathy and support is the most appropriate response in this situation. It is important for the nurse to show understanding and compassion towards the patient, especially when they are feeling emotional about a recent diagnosis. By acknowledging the patient's emotions, the nurse can create a supportive environment that facilitates open communication and helps the patient feel heard and valued. This approach can also help build trust between the patient and the nurse, leading to better outcomes in terms of patient care and overall well-being. Ignoring the patient's emotions, telling them to stop being emotional, or changing the subject may make the patient feel dismissed or isolated, which could negatively impact their mental and emotional state. Thus, offering empathy and support is key in helping the patient cope with their emotions and navigate through their diagnosis.
Question 6 of 9
During surgery, the nurse notices that the patient's temperature is dropping below the normal range. What should the nurse do?
Correct Answer: B
Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.
Question 7 of 9
A patient in the ICU develops catheter-related bloodstream infection (CRBSI) associated with a central venous catheter. What intervention should the healthcare team prioritize to manage the patient's infection?
Correct Answer: A
Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.
Question 8 of 9
A patient with a suspected spinal injury is found unconscious. Which of the following actions should be taken first?
Correct Answer: B
Rationale: When a patient with a suspected spinal injury is found unconscious, the priority action is to secure the airway without jeopardizing the cervical spine. A jaw thrust maneuver is the appropriate technique to open the airway in this situation because it allows for the maintenance of neutral alignment of the cervical spine while ensuring proper ventilation. Moving the patient to a flat surface or applying a cervical collar could potentially worsen the spinal injury if not done correctly, and checking for responsiveness should only be done after ensuring a patent airway. Therefore, the safest and most effective initial action is to perform a jaw thrust maneuver to establish a clear airway.
Question 9 of 9
A nurse administer as extra dose of vaccine to a child and the patient developed adverse reaction and died. She can be sued for _____.
Correct Answer: C
Rationale: In this scenario, the nurse can be sued for malpractice. Malpractice refers to the failure of a professional, in this case, a nurse, to provide the standard of care that a reasonably prudent nurse would have provided in similar circumstances, resulting in harm to the patient. Administering an extra dose of vaccine leading to an adverse reaction and death of the patient is considered a form of medical malpractice as it involves a breach in the standard of care. Generally, malpractice cases involve errors or negligence in the performance of professional duties, which result in harm to the patient.