ATI RN
health assessment exam 1 test bank Questions
Question 1 of 5
While auscultating for heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next?
Correct Answer: A
Rationale: The correct answer is A because documenting the findings is essential for accurate patient care and communication among healthcare professionals. By documenting the unfamiliar sound heard during auscultation, the nurse ensures that the information is recorded for future reference and potential follow-up assessments or interventions. Waiting 10 minutes (
B) may not address the immediate need for documentation. Asking another nurse to double-check (
C) may be helpful but does not address the importance of documenting the finding. Asking the patient to take deep breaths (
D) is not the appropriate next step when an unfamiliar heart sound is detected; documentation is crucial before further assessment or intervention.
Question 2 of 5
A patient drifts off to sleep when there is no stimulation. The nurse can arouse her easily by calling her name, but she remains drowsy during the conversation. The best description of this patient's level of consciousness would be:
Correct Answer: A
Rationale: The correct answer is A: Lethargic. Lethargic is defined as a state of drowsiness or diminished alertness where the patient can be easily aroused by simple stimuli like calling their name, but they remain drowsy and may drift back to sleep. This patient's ability to be aroused by verbal stimuli and their drowsiness during conversation fits the description of lethargic.
Explanation for other choices:
B: Obtunded - Obtunded refers to a more severe level of decreased consciousness where the patient is difficult to fully arouse and may have limited interactions with the nurse.
C: Stuporous - Stuporous indicates an even deeper state of unconsciousness where the patient requires significant stimulation to be aroused and has minimal responsiveness.
D: Semialert - Semialert would describe a patient who is more responsive than lethargic, showing better awareness of their surroundings and able to maintain a conversation more effectively.
Question 3 of 5
Which technique should be used to assess a murmur in a patient's heart?
Correct Answer: B
Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location.
A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs.
C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs.
D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.
Question 4 of 5
A nurse is teaching a patient with chronic kidney disease (CKD) about dietary changes. Which of the following statements by the patient indicates proper understanding?
Correct Answer: A
Rationale: The correct answer is A. In CKD, limiting potassium and phosphorus intake is crucial to prevent electrolyte imbalances and further kidney damage. Excessive protein intake can worsen kidney function, so the patient should not eat as much protein as they want. Increasing fluid intake is beneficial for hydration, but sodas are not recommended due to their high sugar and phosphorus content, which can be harmful for CKD patients.
Therefore, option A is the best choice for proper understanding of dietary changes in CKD.
Question 5 of 5
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse prioritize?
Correct Answer: B
Rationale: The correct answer is B: Providing supplemental oxygen. In COPD, patients often have difficulty breathing due to impaired lung function. Supplemental oxygen helps improve oxygenation and relieves respiratory distress. Prioritizing this intervention is crucial for managing COPD exacerbations and preventing complications. Administering diuretics (
A) may be indicated for comorbid conditions like heart failure but is not a priority in managing COPD. Increasing fluid intake (
C) may not directly address the patient's respiratory distress. Encouraging bed rest (
D) may lead to deconditioning and worsen respiratory function in COPD patients.