ATI RN
Adult Health Nursing Study Guide Answers Questions
Question 1 of 9
You cannot open Claudia's eyes due to dried crust. Which of the following actions would you do?
Correct Answer: D
Rationale: The best course of action in this scenario is to place a warm wet washcloth over Claudia's eyes for at least three minutes. This will help soften and loosen the dried crust, making it easier to gently clean her eyes and open them. Applying eye drops or ointment may not be effective if the crust is blocking her eyes completely. By using a warm wet washcloth, you can improve the ability to clean her eyes effectively and without causing discomfort.
Question 2 of 9
A woman in active labor is experiencing persistent occiput posterior position despite position changes. What nursing intervention is most appropriate to facilitate fetal rotation?
Correct Answer: B
Rationale: The most appropriate nursing intervention to facilitate fetal rotation in a woman experiencing persistent occiput posterior position is to assist the mother into a hands-and-knees position. This position can help encourage the baby to rotate into the optimal occiput anterior position for delivery. By being on her hands and knees, gravity can assist in aiding the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially reduce discomfort during labor. Additionally, hands-and-knees position can help open up the pelvis and create more space for the baby to turn. It is a non-invasive and generally well-tolerated intervention to promote fetal rotation in labor.
Question 3 of 9
While the nurse is taking yhe blood pressure, the patient suddenly stated."They are talking about me!". She was referring to other patients who were waiting for their consultation. Which of the following should be the APPROPRIATE nursing action?
Correct Answer: B
Rationale: The appropriate nursing action in this situation would be to distract the patient's attention. When a patient perceives that others are talking about them, it may indicate feelings of paranoia or anxiety. It's important to help the patient refocus on something else to alleviate their distress. Distracting the patient's attention can help calm them down and allow the blood pressure measurement to proceed smoothly. This approach respects the patient's feelings and helps manage the situation effectively.
Question 4 of 9
A patient presents with fatigue, weakness, and jaundice. Laboratory tests reveal elevated indirect bilirubin levels, reticulocytosis, and positive Coombs test. Which of the following conditions is most likely to cause these findings?
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 9
Which of the following conditions is characterized by chronic hypoxemia, pulmonary hypertension, and right heart failure?
Correct Answer: D
Rationale: Cor pulmonale is a condition characterized by right heart failure secondary to pulmonary hypertension, which is often caused by chronic hypoxemia. Chronic hypoxemia occurs in conditions such as chronic obstructive pulmonary disease (COPD) where there is limited airflow in and out of the lungs, leading to low oxygen levels in the blood. However, the specific characteristic of pulmonary hypertension leading to right heart failure distinguishes cor pulmonale from COPD. Other conditions like idiopathic pulmonary fibrosis (IPF) and pulmonary embolism (PE) may also lead to hypoxemia but are not primarily associated with pulmonary hypertension and right heart failure as in cor pulmonale.
Question 6 of 9
A patient presents with recurrent episodes of fever, sore throat, and cervical lymphadenopathy. Laboratory tests reveal leukocytosis with atypical lymphocytes on peripheral blood smear and positive heterophile antibody test (Monospot test). Which of the following conditions is most likely to cause these findings?
Correct Answer: A
Rationale: The clinical presentation of recurrent fever, sore throat, cervical lymphadenopathy, leukocytosis with atypical lymphocytes, and positive heterophile antibody test (Monospot test) is highly indicative of infectious mononucleosis caused by the Epstein-Barr virus (EBV). EBV is a member of the herpesvirus family and is a common cause of infectious mononucleosis. The atypical lymphocytes seen on peripheral blood smear are reactive T lymphocytes responding to the EBV infection. The Monospot test detects heterophile antibodies produced in response to EBV infection.
Question 7 of 9
Which of the following structures is responsible for storing and concentrating bile produced by the liver until it is needed for digestion?
Correct Answer: B
Rationale: The gallbladder is the structure responsible for storing and concentrating bile produced by the liver until it is needed for digestion. Bile is a digestive fluid that helps in the breakdown of fats during the digestive process. When food containing fats enters the small intestine, the gallbladder contracts and releases bile into the small intestine to aid in the digestion and absorption of fats. The gallbladder acts as a reservoir for bile, storing it until it is needed for digestion.
Question 8 of 9
A client with end-stage renal disease decides against further treatment and requests a "Do Not Resuscitate" (DNR) order. The DNR status is part of the change-of-shift report. The client stops breathing and a nurse begins cardiopulmonary resuscitation. The family is upset and makes a complaint to the charge nurse. The charge nurse appropriately identifies that nurse has committed:
Correct Answer: C
Rationale: Battery occurs when there is an intentional touching of another person without their consent. In this case, the nurse began cardiopulintary resuscitation on a client who had requested a "Do Not Resuscitate" (DNR) order, which means the client did not consent to the resuscitation. This action can be considered as battery because the client's wishes were not respected, and the nurse proceeded with a medical intervention against those wishes, leading to harm and potential legal consequences. This is different from assault, which involves a threat of force, and from defamation and fraud, which are not applicable to this situation.
Question 9 of 9
Which of the following organisms is the MOST common causative agent of urinary tract infection (UTI)?
Correct Answer: D
Rationale: Escherichia coli (E. coli) is the MOST common causative agent of urinary tract infection (UTI), accounting for approximately 80-85% of all cases. E. coli is a type of bacteria that naturally resides in the gastrointestinal tract and can easily migrate to the urinary tract, causing infection. Its prevalence in UTIs is due to various factors such as its ability to adhere to the uroepithelial cells and form biofilms, leading to persistent infections. Therefore, E. coli is the most common organism responsible for UTIs in both community and healthcare settings.