ATI RN
health assessment in nursing test bank Questions
Question 1 of 9
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 9
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 3 of 9
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the:
Correct Answer: A
Rationale: Step-by-step rationale: 1. Nursing interventions are based on nursing diagnosis, which identifies patient's unique health needs. 2. Nursing diagnosis focuses on patient's response to health problems, not just medical conditions. 3. It guides nurses in planning individualized care to meet patient's specific needs. 4. Medical diagnosis (B) focuses on disease pathology, not holistic patient care. 5. Admission diagnosis (C) is a temporary identification of patient's primary reason for admission. 6. Collaborative diagnosis (D) involves joint identification of interprofessional health problems, not specific to nursing care. Summary: The correct answer is A because nursing interventions are tailored based on nursing diagnosis, which considers patient's responses to health issues. Medical diagnosis, admission diagnosis, and collaborative diagnosis do not provide the same level of individualized and holistic care planning as nursing diagnosis.
Question 4 of 9
A nurse is caring for a patient with a history of chronic kidney disease (CKD). The nurse should monitor for which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In CKD, kidneys struggle to excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac arrhythmias. Hypokalemia (B) is unlikely in CKD due to impaired potassium excretion. Hyperglycemia (C) is more commonly associated with diabetes rather than CKD. Hypercalcemia (D) is not a typical complication of CKD; instead, patients with CKD often experience low calcium levels.
Question 5 of 9
A 90-year-old patient tells the nurse that he is unable to remember the names of the medications he is taking or what they are for. An appropriate response would be:
Correct Answer: D
Rationale: The correct answer is D because asking the patient's family to bring in the medications will ensure accurate identification and understanding of the medications. This step is crucial in ensuring the patient's safety and well-being. Choice A is incorrect as appearance alone may not provide accurate information. Choice B is dismissive and does not address the issue. Choice C focuses on duration rather than addressing the immediate concern of medication identification.
Question 6 of 9
A nurse preparing to conduct a prenatal class is aware that which of the following groups is at highest risk for infant mortality?
Correct Answer: D
Rationale: The correct answer is D: First Nations people. First Nations people in Canada have historically faced systemic barriers to healthcare, leading to higher rates of infant mortality compared to other groups. This includes socio-economic factors, access to quality healthcare, and cultural differences impacting healthcare practices. European Canadians, Asian Canadians, and African Canadians do not face the same level of disparities and risk factors contributing to infant mortality rates as First Nations people. It is essential for healthcare providers to understand these disparities to address the health needs of First Nations communities effectively.
Question 7 of 9
A nurse is caring for a patient with hypertension. Which of the following lifestyle changes would the nurse prioritize to help manage the patient's blood pressure?
Correct Answer: B
Rationale: The correct answer is B. Losing weight and increasing physical activity help manage blood pressure by reducing excess body weight, improving heart function, and enhancing blood flow. This leads to lower blood pressure levels. A: Increasing sodium intake would worsen hypertension by promoting fluid retention and raising blood pressure. C: Consuming more processed foods often includes high levels of sodium, unhealthy fats, and additives that can negatively impact blood pressure. D: Limiting fluid intake is not a primary lifestyle change for managing hypertension; adequate fluid intake is important for overall health and blood pressure regulation.
Question 8 of 9
Which of the following responses might the nurse expect during the functional assessment of a patient whose leg is in a cast?
Correct Answer: D
Rationale: The correct answer is D because the nurse would expect the patient to demonstrate functional independence in activities like transferring from a wheelchair to the bed despite having a leg in a cast. This response indicates good mobility and strength, which are positive signs of recovery. Choices A, B, and C are incorrect as they do not directly address the functional assessment of the patient. Choice A provides historical information, choice B focuses on pain management, and choice C mentions a self-care routine that is not related to functional ability.
Question 9 of 9
A nurse is assessing a patient's family history. Which of the following would be most relevant to include in the assessment?
Correct Answer: A
Rationale: The correct answer is A because a family history of heart disease, cancer, and diabetes can provide crucial information about potential genetic predispositions and health risks for the patient. This information helps the nurse assess the patient's risk factors and tailor preventative measures or interventions accordingly. Choice B is incorrect as siblings' hobbies and interests are not relevant to the patient's medical history. Choice C is incorrect as the father's occupation does not directly impact the patient's health risks. Choice D is incorrect as the patient's favorite sports team is not relevant to assessing the patient's family history for health-related issues.