Adult Health Nursing Quizlet Final

Questions 164

ATI RN

ATI RN Test Bank

Adult Health Nursing Quizlet Final Questions

Question 1 of 5

The patient began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. The patient complains of difficulty of breathing, itching and a tight sensation in the chest. Which is the IMMEDIATE action of the nurse?

Correct Answer: D

Rationale: The symptoms described by the patient indicate a potential transfusion reaction, such as a hemolytic reaction or allergic reaction. The immediate action the nurse should take in such a situation is to stop the infusion of the packed red blood cells. This will help prevent further complications and ensure the safety of the patient. After stopping the infusion, the nurse should assess the patient's condition, monitor vital signs, and inform the healthcare team, including the physician, regarding the situation. Once the patient is stable, further investigations can be conducted to determine the cause of the reaction.

Question 2 of 5

A patient receiving palliative care for end-stage dementia experiences agitation and restlessness. What intervention should the palliative nurse prioritize to address the patient's symptoms?

Correct Answer: C

Rationale: The most appropriate intervention for a patient with end-stage dementia experiencing agitation and restlessness is to create a calm and soothing environment to promote relaxation. Patients with dementia often respond positively to a familiar and tranquil setting, which can help reduce their symptoms of agitation and restlessness. This approach is preferred over administering antipsychotic medications or recommending physical exercise, as these may not be feasible or beneficial for patients in the advanced stages of dementia. Referring the patient to a psychiatrist may not address the immediate need for symptom management and can be considered if other interventions are ineffective. Creating a calm environment, such as dim lighting, soft music, and familiar objects, can help provide comfort and reduce distress for the patient.

Question 3 of 5

A pregnant woman presents with fever, chills, and abdominal pain localized to the right lower quadrant. On examination, she has rebound tenderness and guarding. Which of the following conditions is the most likely cause of these symptoms?

Correct Answer: C

Rationale: Acute appendicitis is the most likely cause of the symptoms described in the pregnant woman. The classic presentation of acute appendicitis includes fever, chills, abdominal pain localized to the right lower quadrant, rebound tenderness, and guarding. Pregnant women are at a slightly higher risk of developing appendicitis due to anatomic changes and increased abdominal pressure during pregnancy, which can lead to an atypical presentation of symptoms. Prompt diagnosis and surgical intervention are crucial to prevent complications such as perforation, which can be detrimental for both the mother and the fetus.

Question 4 of 5

When preparing the patient for suctioning, what is the FIRST step?

Correct Answer: D

Rationale: Before any procedure, it is crucial to ensure that you have the proper authorization and guidelines in place. By checking the physician's order and the patient care plan, you confirm that suctioning is indeed needed and that you follow the specific instructions for that patient. This step helps ensure patient safety and effective care delivery. Once you have verified this information, you can proceed with gathering equipment, performing hand hygiene, and assessing the patient's condition as necessary.

Question 5 of 5

What is the first step in the management of a chemical splash to the eyes?

Correct Answer: A

Rationale: The first step in the management of a chemical splash to the eyes is to irrigate the eyes with clean water. Flushing the affected eye with water helps to remove the chemical and minimize any potential injury. It is important to continue irrigation for at least 15-20 minutes to ensure thorough removal of the chemical. This prompt action can help prevent further damage to the eye and surrounding tissue. It is crucial to remember not to delay irrigation to seek medical advice first, as immediate irrigation is vital in such situations. After irrigating the eyes, further assessment and treatment can be carried out based on the severity of the injury.

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