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 presents with a prolonged latent phase, characterized by irregular and ineffective contractions. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?

Correct Answer: B

Rationale: Maternal anxiety can contribute to a prolonged latent phase during labor. Stress and anxiety can trigger the release of stress hormones such as adrenaline, which can interfere with the production of oxytocin, the hormone responsible for initiating contractions. This can result in irregular and ineffective contractions, leading to a prolonged latent phase. It is important for the nurse to assess the woman's anxiety levels and provide reassurance and support to help facilitate the progression of labor.

Question 2 of 5

Nurse Mary had observedthat most patients with hypertension stop taking their medications and heard them saying "I feel good already" Which is the APPROPRIATE nursing diagnosis?

Correct Answer: D

Rationale: The appropriate nursing diagnosis for this situation is "Ineffective coping" because the patients with hypertension who stop taking their medications despite feeling good may be using this behavior as a maladaptive coping mechanism. It suggests that they might not fully understand the importance of medication adherence or are struggling to accept their diagnosis. By not adhering to their prescribed treatment, they are putting themselves at risk for complications associated with uncontrolled hypertension. Therefore, the nursing diagnosis of "Ineffective coping" addresses the patients' inability to deal with their condition in a healthy manner, leading to noncompliance with their treatment regimen.

Question 3 of 5

Twelve hours after vaginal delivery, Nurse Kayla palpates the fundus of a primiparous patient and finds it to be firm, above the umbilicus and deviated to the right. What is the BEST thing for Nurse Kayla to do for the patient?

Correct Answer: C

Rationale: The best thing for Nurse Kayla to do for the patient is to encourage her to ambulate and to void. In this scenario, the fundus being firm, above the umbilicus, and deviated to the right indicates uterine atony with a full bladder. This finding is suggestive of a distended bladder pushing the uterus upwards and to the right. Encouraging the patient to ambulate helps promote uterine contractions, which can aid in the firming up of the uterus. Additionally, emptying the bladder will help the uterus to contract and return to its midline position. This intervention is non-invasive and promotes normal postpartum recovery without the need for medication or excessive manipulation.

Question 4 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 5 of 5

A patient presents with bone pain, fatigue, and frequent infections. Laboratory tests reveal pancytopenia, hypocellular bone marrow, and absence of reticulocytes. Which of the following conditions is most likely to cause these findings?

Correct Answer: A

Rationale: Aplastic anemia is a condition characterized by a reduction in the number of all three blood cell types: red blood cells, white blood cells, and platelets. The patient's presentation of bone pain, fatigue, frequent infections, pancytopenia (decreased counts of all blood cell types), hypocellular bone marrow (reduced cellularity in the bone marrow), and absence of reticulocytes is indicative of aplastic anemia.

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