Foundations and Adult Health Nursing Study Guide Answers

Questions 164

ATI RN

ATI RN Test Bank

Foundations and Adult Health Nursing Study Guide Answers Questions

Question 1 of 5

A woman in active labor is diagnosed with uterine rupture. What is the priority nursing action?

Correct Answer: A

Rationale: The priority nursing action for a woman diagnosed with uterine rupture during labor is to prepare for immediate cesarean section. Uterine rupture is a serious obstetric emergency that can lead to severe maternal and fetal complications, including hemorrhage, fetal distress, and injury to both mother and baby. A cesarean section is necessary to deliver the baby promptly and address any potential complications, such as controlling bleeding and ensuring the safety of both the mother and the baby. Time is critical in these situations, and prompt surgical intervention is essential to optimize outcomes. Administering intravenous oxytocin or assisting the mother into a hands-and-knees position would not address the immediate risks associated with uterine rupture. Initiating cardiopulmonary resuscitation (CPR) is only necessary if the mother's condition deteriorates to the point of cardiac or respiratory arrest, which may occur as a result of significant hemorrhage or other complications associated with uterine

Question 2 of 5

A patient with chronic kidney disease presents with periorbital edema, hypertension, and proteinuria. Laboratory findings reveal elevated serum creatinine and urea levels, hyperkalemia, and metabolic acidosis. What is the most likely diagnosis?

Correct Answer: D

Rationale: The constellation of symptoms presented (periorbital edema, hypertension, proteinuria) along with the laboratory findings (elevated creatinine and urea levels, hyperkalemia, metabolic acidosis) are classical signs of chronic kidney disease (CKD). In CKD, the kidneys gradually lose their function over time, leading to impaired filtration of waste products and electrolyte imbalance. The presence of hypertension and proteinuria are common in CKD due to the compromised renal function. Additionally, elevated serum creatinine and urea levels, hyperkalemia, and metabolic acidosis are indicative of kidney dysfunction.

Question 3 of 5

A nurse is preparing to perform a central venous catheter (CVC) dressing change for a patient. What action should the nurse prioritize to minimize the risk of infection?

Correct Answer: C

Rationale: The nurse should prioritize removing the old dressing and applying a new dressing using sterile technique to minimize the risk of infection during a central venous catheter (CVC) dressing change. This is because the most critical step in preventing infection is maintaining a clean and sterile environment around the CVC insertion site. By using sterile technique, the nurse can reduce the introduction of microorganisms that could potentially lead to infection. Wearing sterile gloves and cleaning the insertion site with an alcohol-based antiseptic solution are important steps as well, but the key priority lies in applying the new dressing using sterile technique to prevent contamination and reduce the risk of infection.

Question 4 of 5

The public health nurse must participate in the essential services that are relevant and accessible to the family and the community. These include:

Correct Answer: C

Rationale: The public health nurse's participation in the essential services that are relevant and accessible to the family and the community includes informing, educating, and empowering the people about health. This is a critical aspect of the role of a public health nurse as it involves engaging with individuals and communities to provide them with accurate information about health promotion, disease prevention, and access to healthcare services. By informing, educating, and empowering the people about health, public health nurses can help individuals and communities make informed decisions about their health and well-being, leading to improved health outcomes and overall community health.

Question 5 of 5

A woman in active labor demonstrates persistent fetal malpresentation, with the fetus in a transverse lie position. What nursing intervention should be prioritized to address this abnormal labor presentation?

Correct Answer: C

Rationale: In cases of persistent fetal malpresentation, such as a transverse lie position, a cesarean section is often the safest and most effective intervention to address the abnormal labor presentation. Delivering a baby in a transverse lie position vaginally is associated with high risks, including fetal complications such as umbilical cord prolapse and head entrapment. Therefore, to ensure the safety of both the mother and the baby, a cesarean section is usually the most appropriate and timely intervention to address this situation. It is crucial to prioritize the immediate preparation and facilitation of a cesarean section in cases of persistent fetal malpresentation to prevent potential complications and ensure the best outcome for the mother and the baby.

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