ATI RN
health assessment in nursing test bank Questions
Question 1 of 5
A nurse is assessing a patient who is post-operative following a hip replacement. Which of the following is the most important nursing priority after surgery?
Correct Answer: C
Rationale: The correct answer is C: Preventing deep vein thrombosis (DVT). It is the most important nursing priority after hip replacement surgery because patients are at high risk for DVT due to immobility and altered blood flow. DVT can lead to serious complications like pulmonary embolism. Monitoring for infection (B) is important but preventing DVT takes precedence. Managing pain (A) is essential but not the top priority. Ensuring proper positioning (D) is important for preventing complications, but DVT prevention is more critical post-hip replacement surgery.
Question 2 of 5
A nurse is caring for a patient who has undergone a knee replacement. The nurse should encourage which of the following to promote recovery?
Correct Answer: B
Rationale: The correct answer is B: Ambulation as soon as possible after surgery. Ambulation helps prevent complications like blood clots and aids in circulation and muscle strength. Bed rest can lead to stiffness and decrease in range of motion. Limiting physical activity delays recovery. Prolonged use of a cast can hinder mobility and delay rehabilitation.
Question 3 of 5
A nurse is caring for a patient who is post-operative following hip replacement surgery. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation. This is because early ambulation is crucial in preventing complications such as blood clots and muscle atrophy post hip replacement surgery. It helps improve circulation, prevent joint stiffness, and promote healing. Administering pain medication regularly (A) is important but not the top priority. Providing wound care and dressing changes (C) and monitoring for signs of infection (D) are also important but secondary to early ambulation in preventing complications and promoting recovery.
Question 4 of 5
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Administering supplemental oxygen as needed. This is the priority intervention for a patient with COPD because it helps improve oxygenation and relieve respiratory distress, which is the main concern in COPD. Supplemental oxygen also helps reduce the workload on the heart and other organs. Encouraging physical activity (B) is important for overall health but may not be the priority in acute exacerbations. Administering antibiotics regularly (C) is not necessary unless there is a documented infection. Providing increased fluid intake (D) is important for maintaining hydration but is not the priority intervention in this case.
Question 5 of 5
A nurse is teaching a patient with diabetes about self-management. Which of the following statements by the patient indicates the need for further education?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Taking insulin only when blood sugar is high can lead to uncontrolled levels. 2. Regular insulin dosing is essential for diabetes management. 3. Monitoring blood sugar regularly helps in adjusting insulin doses. 4. Eating a balanced diet and exercising are key components of diabetes management. 5. Reporting signs of infection is crucial due to diabetes-related complications.