ATI RN
Adult Health Nursing Test Bank Questions
Question 1 of 9
Which of the following interventions is recommended for managing a patient with suspected pelvic inflammatory disease (PID)?
Correct Answer: A
Rationale: The correct answer is A: Empiric antibiotic therapy directed against common pathogens. This is recommended for managing PID because it helps treat the infection and prevent complications. Antibiotics target the underlying bacterial infection causing PID. Surgical exploration (B) is not the initial treatment for PID. Hormonal therapy (C) is not indicated for PID management. Symptomatic treatment with NSAIDs (D) can help with pain but does not address the infection itself.
Question 2 of 9
Norse Sophie checks the gauge of the patient ' s intravenous catheter. Which is the smallest gauge catheter that the nurse can use to administer blood?
Correct Answer: B
Rationale: The correct answer is B: 20-Gauge. The smaller the gauge number, the larger the diameter of the catheter. Blood transfusions typically require a larger catheter size to prevent hemolysis and ensure proper flow. A 20-Gauge catheter is larger than 22-Gauge, 18-Gauge, and 12-Gauge, making it suitable for administering blood. 22-Gauge is too small and can cause hemolysis, 18-Gauge is smaller than the recommended size for blood transfusions, and 12-Gauge is too large and can cause damage to the vein.
Question 3 of 9
While patient Sarah is confined in the hospital, the safety measure to be observed by the nurses is prevention from fall. This is brought about by the patient being prone to fracture as a result of________.
Correct Answer: B
Rationale: The correct answer is B: osteoporosis. Osteoporosis is a condition characterized by weakened bones, making individuals more susceptible to fractures, especially with minor trauma or falls. In the context of a patient prone to fractures, nurses should be particularly cautious about fall prevention. A: The aging process alone does not necessarily lead to an increased risk of fractures. While aging is a risk factor for osteoporosis, it is not the direct cause of fractures in this case. C: Changes in vision can contribute to an increased risk of falls, but it is not the primary reason for the patient being prone to fractures in this scenario. D: Hematologic conditions may affect bone health, but they are not typically the primary cause of increased fracture risk in patients.
Question 4 of 9
A postpartum client presents with persistent, severe perineal pain and swelling following a vaginal delivery. On assessment, the nurse notes ecchymosis and tenderness of the perineum. Which nursing action is most appropriate?
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The client presenting with persistent, severe perineal pain and swelling, along with ecchymosis and tenderness of the perineum, could be indicative of complications such as a perineal hematoma. A perineal hematoma is a collection of blood in the perineal tissues and can be a serious postpartum complication requiring prompt medical attention. Therefore, it is crucial to alert the healthcare provider so that appropriate assessment, management, and treatment can be initiated promptly. Applying ice packs or encouraging the client to sit on a donut cushion may not be sufficient in this situation, and administering additional analgesic medication should be done only after the healthcare provider has assessed and determined the cause of the symptoms.
Question 5 of 9
Which of the following actions should be taken first when encountering a person experiencing an allergic reaction with signs of respiratory distress?
Correct Answer: D
Rationale: The correct answer is D: Assess the severity of the reaction. This should be the first action taken because it helps determine the urgency of the situation and guides subsequent steps. Assessing the severity allows for appropriate intervention - from calling emergency services if the reaction is severe, to administering medication if necessary. A: Administering an epinephrine auto-injector should only be done if the severity of the reaction warrants it, as it is a potent medication that can have serious side effects if used inappropriately. B: Positioning the person comfortably is important, but assessing the severity of the reaction takes precedence to ensure prompt and appropriate care. C: Monitoring vital signs is important, but assessing the severity of the reaction is crucial in determining the immediate course of action.
Question 6 of 9
While performing the admission assessment of a new client, the nurse observed that the client brought a bottle of over-the-counter pain medication to the hospital. The nurse failed to document this or remove the medication from the room. Subsequently, the client experienced a serious adverse drug reaction as a result of the interaction between this drug and one of the drugs that the client was prescribed in the hospital. This nurse may be guilty of what?
Correct Answer: A
Rationale: The correct answer is A: Malpractice. The nurse's failure to document and remove the over-the-counter medication, which led to a serious adverse drug reaction, constitutes malpractice. Malpractice refers to negligence or failure to provide the standard of care expected in a professional setting. In this case, the nurse's actions directly resulted in harm to the client, which is a clear example of malpractice. Incorrect Choices: B: Failure of duty to warn - This choice implies that the nurse had a duty to warn the client about the potential drug interaction, which may not necessarily be the case. The primary issue here is the nurse's failure to document and remove the medication, not a failure to warn. C: Assault - Assault involves intentional harm or threat of harm, which is not applicable in this scenario where the harm was due to negligence. D: Incompetence - While the nurse's actions may demonstrate incompetence, the more specific legal term for this situation would be malpractice, as it directly
Question 7 of 9
A patient presents with a painful, vesicular rash following a linear pattern on the left forearm. The patient reports a history of gardening without gloves. Which of the following conditions is most likely responsible for this presentation?
Correct Answer: B
Rationale: The correct answer is B: Herpes simplex virus infection. The presentation of a painful, vesicular rash following a linear pattern on the left forearm is characteristic of herpes simplex virus infection, specifically herpes zoster (shingles). The linear pattern is due to the virus following a specific nerve pathway. This is different from the other choices - A: Allergic contact dermatitis typically presents as a diffuse rash at the site of contact with an allergen, not a linear pattern. C: Scabies presents with burrows and papules, not vesicles in a linear pattern. D: Poison ivy dermatitis causes a diffuse rash, not a linear vesicular rash.
Question 8 of 9
When a nurse supports the welfare of the patient in relation to health, safety and personal rights, the ethical principle followed is
Correct Answer: D
Rationale: The correct answer is D: advocacy. Advocacy involves actively supporting and promoting the welfare and rights of the patient. Nurses advocate for their patients by ensuring their health, safety, and personal rights are upheld. This ethical principle goes beyond just fulfilling responsibilities or being accountable for one's actions. Responsibility (A) focuses on duties and tasks, accountability (B) is about being answerable for one's actions, and confidentiality (C) pertains to maintaining patient privacy. In this context, advocacy is the most appropriate choice as it encompasses actively working to protect and promote the best interests of the patient.
Question 9 of 9
A patient with a suspected autoimmune disorder exhibits antibodies directed against self-antigens, leading to tissue damage and inflammation. Which of the following mechanisms is primarily responsible for the development of autoimmune diseases?
Correct Answer: A
Rationale: The correct answer is A: Loss of self-tolerance. This is because autoimmune diseases result from a breakdown in the immune system's ability to distinguish between self and non-self antigens, leading to the production of antibodies against self-antigens. When self-tolerance is lost, immune cells mistakenly target the body's own tissues, causing tissue damage and inflammation. Choice B (Failure of innate immunity) is incorrect because autoimmune diseases are primarily driven by adaptive immunity rather than innate immunity. Choice C (Defective T cell activation) is incorrect as T cells play a critical role in the immune response to self-antigens in autoimmune diseases. Choice D (Impaired phagocytosis) is incorrect as phagocytosis is a mechanism primarily involved in the removal of pathogens, not in the development of autoimmune diseases.