ATI RN
health assessment test bank Questions
Question 1 of 5
A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be:
Correct Answer: C
Rationale: The correct answer is C: subjective. Subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient's report of feeling nervous, nauseated, and hot is subjective because it reflects their personal sensations and cannot be measured or observed directly by the nurse. Objective data (choice
A) is measurable and observable, such as vital signs or physical examination findings. Reflective (choice
B) and introspective (choice
D) do not accurately describe the type of data provided by the patient in this scenario. The patient's symptoms are subjective because they are based on the patient's own feelings and experiences, making choice C the most appropriate answer.
Question 2 of 5
A nurse is assessing a patient who has a history of deep vein thrombosis (DVT). Which of the following findings would be most concerning?
Correct Answer: C
Rationale: The correct answer is C: Shortness of breath and chest pain. This is most concerning because it could indicate a pulmonary embolism, a serious complication of DVT where a blood clot travels to the lungs. Shortness of breath and chest pain are signs of compromised respiratory and cardiac function.
A: Pain and swelling in the leg are common symptoms of DVT but not as concerning as symptoms of a pulmonary embolism.
B: Redness and warmth around the affected area are typical signs of inflammation associated with DVT but do not indicate a life-threatening complication like a pulmonary embolism.
D: Pale skin and decreased pulse in the affected leg could be signs of compromised circulation due to DVT, but they are not as immediately life-threatening as symptoms of a pulmonary embolism.
Question 3 of 5
A nurse is caring for a patient with chronic kidney disease (CKD). Which of the following lab results would the nurse expect to be elevated in this patient?
Correct Answer: A
Rationale: The correct answer is A: Blood urea nitrogen (BUN). In CKD, the kidneys are unable to effectively filter waste products, leading to an increase in BUN levels. Elevated BUN indicates impaired kidney function. Calcium, potassium, and sodium levels may also be affected in CKD, but they are more likely to be imbalanced rather than consistently elevated. Calcium levels may be low due to impaired vitamin D activation, potassium levels may be high due to decreased excretion, and sodium levels can fluctuate based on fluid status.
Therefore, while these lab values may be abnormal in CKD, BUN is the most consistently elevated marker of kidney dysfunction.
Question 4 of 5
A patient is at the clinic to have her blood pressure checkeShe has been coming to the clinic weekly since her medications were changed 2 months ago. The nurse should:
Correct Answer: A
Rationale:
Rationale:
1. Collecting a follow-up database ensures up-to-date information.
2. It allows for monitoring of medication effectiveness and any new symptoms.
3. Checking the blood pressure is essential but needs current context.
4. Asking the patient to read her record may not provide all necessary updates.
5. The complete health history is crucial but obtaining it first may delay urgent blood pressure check.
Question 5 of 5
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following in the immediate post-operative period?
Correct Answer: B
Rationale: The correct answer is B: Encouraging deep breathing and coughing exercises. This is prioritized in the immediate post-operative period to prevent respiratory complications like atelectasis and pneumonia. Deep breathing helps to expand the lungs and coughing helps clear secretions. Administering pain medication (
A) is important but not the top priority. Monitoring for signs of infection (
C) is crucial but usually done after ensuring respiratory stability. Providing solid food (
D) is contraindicated initially to prevent post-operative complications like ileus.