ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 9
Who among the passengers will take PRIORITY for the rescue team to transport to the hospital?
Correct Answer: C
Rationale: In emergency situations, pregnant women are typically given priority when it comes to transportation to the hospital. This is because they have unique medical needs and potential complications that require immediate attention. It is important to ensure the well-being of both the mother and the unborn child. Additionally, the health and safety of the unborn child are critical considerations in determining priority for medical treatment and transport. Therefore, the pregnant woman should be the priority for the rescue team to transport to the hospital.
Question 2 of 9
A patient is prescribed an opioid analgesic for postoperative pain management. Which nursing intervention is essential for preventing respiratory depression in the patient?
Correct Answer: B
Rationale: Monitoring oxygen saturation with pulse oximetry is essential for preventing respiratory depression in a patient prescribed an opioid analgesic. Opioid analgesics can suppress the respiratory drive, leading to respiratory depression. By constantly monitoring the patient's oxygen saturation levels with pulse oximetry, nurses can promptly detect any signs of respiratory depression and intervene early to prevent serious complications. This allows for timely adjustments in the medication dosage or administration of other supportive measures to maintain adequate oxygenation and prevent respiratory compromise. Administering naloxone prophylactically may be necessary in case of an opioid overdose but is not typically done as a preventive measure. Encouraging deep breathing exercises can help prevent respiratory complications postoperatively but may not be sufficient in the presence of opioid-induced respiratory depression. Administering bronchodilators as needed is not directly related to preventing respiratory depression caused by opioid analgesics.
Question 3 of 9
A patient presents with symptoms of polyuria, polydipsia, and polyphagia. Laboratory tests reveal hyperglycemia and glycosuria. Which type of diabetes mellitus is the patient most likely experiencing?
Correct Answer: A
Rationale: The patient is most likely experiencing Type 1 diabetes mellitus based on the presentation of polyuria, polydipsia, polyphagia, hyperglycemia, and glycosuria. Type 1 diabetes is characterized by autoimmune destruction of the beta cells in the pancreas, leading to absolute insulin deficiency. This results in high blood sugar levels (hyperglycemia) and glucose spilling into the urine (glycosuria). Patients with Type 1 diabetes often present with the classic symptoms of polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger) due to the body's inability to utilize glucose for energy effectively. Management of Type 1 diabetes typically involves lifelong insulin therapy to maintain blood sugar levels within a target range.
Question 4 of 9
A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?
Correct Answer: B
Rationale: The client should be assisted to lie in bed on the unaffected side for a thoracentesis procedure. This position allows for better access to the pleural space for the insertion of a needle to aspirate the fluid or air. Gravity helps to separate the fluid or air, making it closer to the chest wall for easier removal. Additionally, this position reduces the risk of injury to the lung or other structures, as the needle is directed away from these vital structures. Lying on the unaffected side also helps in preventing potential complications and ensures the safety and effectiveness of the procedure.
Question 5 of 9
Which law declares that the policy of the State is to promote and upgrade the practice of profession in the country?
Correct Answer: C
Rationale: RA 9173, also known as the Philippine Nursing Act of 2002, is the law that declares the State policy to promote and upgrade the practice of the nursing profession in the Philippines. This law provides for the regulation and maintenance of high standards of nursing education and practice in the country. It aims to ensure the welfare and professional growth of Filipino nurses and to safeguard the health of the public by maintaining competency and professionalism in the nursing profession. Therefore, RA 9173 is the correct choice that reflects the State's policy to promote and upgrade the practice of the nursing profession in the Philippines.
Question 6 of 9
Nurse Selma is preparing to administer ofloxacin eardrop on Catherine per Doctor's order. She needs to hold the bottle with her hands to warm up the solution to prevent dizziness for
Correct Answer: B
Rationale: Warming up ofloxacin eardrops before administering is done to prevent dizziness, which can occur if a cold solution is placed in the ear. Holding the bottle with hands for about 1 to 2 minutes is usually sufficient to warm up the solution to a comfortable temperature for the patient. Warming the solution for too long, such as 5-6 minutes, may not be necessary and could potentially waste time. So, the correct duration for warming up ofloxacin eardrops is 1 to 2 minutes.
Question 7 of 9
Which of the following statements accurately describes the role of major histocompatibility complex (MHC) molecules in antigen presentation?
Correct Answer: B
Rationale: Major histocompatibility complex (MHC) class I molecules are responsible for presenting endogenous antigens, such as viral or intracellular proteins, to CD8+ T cells. These antigens are derived from within the cell, either synthesized within the cell itself or taken up from the cytoplasm. CD8+ T cells, also known as cytotoxic T cells, recognize antigens presented by MHC class I molecules and play a key role in cell-mediated immunity by destroying infected or abnormal cells.
Question 8 of 9
A client has undergone a lymph node biopsy. The nurse anticipates that the report will reveal which result if the client has Hodgkin's Lymphoma?
Correct Answer: A
Rationale: Reed-Sternberg cells are large, abnormal lymphocytes that are characteristic of Hodgkin's Lymphoma. They are typically found in the affected lymph nodes of individuals with Hodgkin's Lymphoma when examined under a microscope. Identifying Reed-Sternberg cells in a lymph node biopsy is a key diagnostic feature of Hodgkin's Lymphoma. This distinguishes Hodgkin's Lymphoma from other types of lymphomas that do not have Reed-Sternberg cells.
Question 9 of 9
Nurse Reese is preparing the patient assignment t for the day and needs to assign patients to a midwife and nursing assistant. Which patient should the nurse assign to the midwife because of patient needs that cannot be met by the nursing assistant? A patient requiring________.
Correct Answer: A
Rationale: The patient requiring a dressing change of post-caesarian surgery should be assigned to the midwife because this task involves specialized knowledge and skills related to wound care and post-operative care. Performing a dressing change for a post-caesarian surgery patient requires expertise to ensure proper hygiene, wound healing, and prevention of post-operative complications. This task goes beyond the scope of practice for a nursing assistant and should be done by a healthcare professional with higher qualifications and training, such as a midwife.