ATI RN
test bank for health assessment Questions
Question 1 of 5
What is the priority intervention for a client who is experiencing an acute asthma attack?
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. During an acute asthma attack, the priority intervention is to immediately open the airways to improve breathing. Bronchodilators, such as albuterol, work rapidly to dilate the bronchioles and relieve bronchospasms, making it the most effective initial treatment. Corticosteroids (
B) are used for long-term control, not immediate relief. Applying oxygen and administering albuterol (
C) is close, but bronchodilators should be given first for quicker relief. Applying a cold compress (
D) is not appropriate for managing an asthma attack.
Question 2 of 5
What should the nurse do if a client experiences an allergic reaction to a medication?
Correct Answer: D
Rationale: The correct answer is D because when a client experiences an allergic reaction to a medication, the nurse should monitor for signs of infection as allergic reactions can sometimes lead to secondary infections. By closely monitoring the client for signs of infection, the nurse can promptly intervene and provide appropriate treatment.
A: Discontinuing the medication is important but not the immediate priority when dealing with an allergic reaction.
B: Notifying the healthcare provider is important, but monitoring for signs of infection takes precedence in this situation.
C: Administering antihistamines may help with allergic symptoms but does not address the potential risk of secondary infection.
Question 3 of 5
What is the most important action when caring for a client on intravenous heparin?
Correct Answer: A
Rationale: The correct answer is A: Monitor aPTT levels. This is crucial in intravenous heparin therapy to ensure the therapeutic range is maintained for anticoagulation without causing bleeding. Monitoring aPTT helps adjust heparin dosage to prevent clot formation or excessive bleeding.
B: Monitoring for bleeding is important but not the most important action compared to monitoring aPTT levels for appropriate dosing.
C: Checking platelet count is important for some anticoagulants like heparin, but aPTT monitoring is more directly related to heparin's anticoagulant effect.
D: Administering a heparin antidote (protamine sulfate) is necessary in case of heparin overdose or in emergency situations but is not the primary action in routine care.
Question 4 of 5
What should the nurse do first when a client is experiencing an allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for an allergic reaction as it helps to reverse severe symptoms like swelling, difficulty breathing, and low blood pressure. Administering epinephrine promptly can prevent the allergic reaction from escalating into a life-threatening situation. Antihistamines (choice
B) may be given after epinephrine for symptom relief but are not as immediate in action. Monitoring vital signs (choice
C) is important, but administering epinephrine takes precedence in managing the allergic reaction. Providing a cold compress (choice
D) may help with local swelling but does not address the systemic effects of the allergic reaction.
Question 5 of 5
What is the most appropriate action for a nurse to take when a client's blood pressure drops significantly?
Correct Answer: A
Rationale: The correct action is to administer IV fluids when a client's blood pressure drops significantly. This helps increase blood volume and improve circulation, stabilizing the blood pressure. Administering pain medication (
B) does not address the root cause of low blood pressure. Applying a heating pad (
C) is not effective in treating low blood pressure. Monitoring the client's respiratory rate (
D) is important but not the immediate action needed to address a significant drop in blood pressure.