ATI RN
Health Assessment Practice Questions Questions
Question 1 of 9
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. This is the priority intervention as it helps prevent complications such as blood clots and pneumonia, promotes circulation, and aids in faster recovery. Ambulation also helps maintain joint mobility and muscle strength. Administering pain medications (B) is important but not the priority. Providing wound care (C) and monitoring for infection (D) are important, but ambulation takes precedence in preventing complications.
Question 2 of 9
What should the nurse do when a client develops severe shortness of breath after surgery?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. This is the priority intervention to address severe shortness of breath, ensuring the client receives adequate oxygenation. Administering oxygen helps improve oxygen saturation levels and supports respiratory function. Encouraging deep breathing (B) may exacerbate the client's distress. Elevating the head of the bed (C) can help improve breathing but does not address the immediate need for oxygen. Administering antibiotics (D) is not indicated for shortness of breath unless there is an underlying infection causing it.
Question 3 of 9
Which assessment finding indicates a positive response to Heparin therapy?
Correct Answer: B
Rationale: The correct answer is B: increased fibrinogen. Heparin therapy works by inhibiting clot formation by enhancing the activity of antithrombin III, which leads to decreased levels of fibrinogen. Therefore, an increase in fibrinogen levels would indicate a positive response to Heparin therapy. Incorrect choices: A: increased platelet count - Heparin therapy does not typically affect platelet count, so an increase in platelet count would not indicate a positive response to Heparin therapy. C: decreased fibrin split products - Decreased fibrin split products may not necessarily indicate a positive response to Heparin therapy, as other factors can also influence their levels. D: decreased bleeding - While decreased bleeding can be a positive outcome of Heparin therapy, it is not a direct assessment finding that indicates a positive response to the therapy.
Question 4 of 9
During the examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse suspects that:
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Enlargement of the thyroid gland during pregnancy is a normal finding due to hormonal changes. 2. The thyroid gland enlarges to meet the increased demands of thyroid hormone production. 3. This condition is known as gestational thyrotoxicosis and is usually benign. 4. No further testing is needed for thyroid cancer unless other concerning symptoms are present. Summary: A: Not relevant as iodine deficiency is not typically associated with thyroid enlargement in pregnancy. B: Incorrect as early signs of goitre would involve more pronounced symptoms than just slight enlargement. D: Unnecessary as thyroid cancer is not a common concern in this scenario of a slightly enlarged thyroid in the third trimester of pregnancy.
Question 5 of 9
A nurse is assessing a patient with a history of smoking. The patient reports a persistent cough that has worsened over the past few months. The nurse would be most concerned about the possibility of:
Correct Answer: B
Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). The patient's history of smoking, persistent cough, and worsening symptoms over months are indicative of COPD, a progressive lung disease commonly caused by smoking. Asthma (A) typically presents with intermittent symptoms, bronchitis (C) may cause cough but not necessarily worsening over time, and pulmonary embolism (D) is characterized by sudden onset symptoms and is less likely in this case. COPD is the most concerning due to the patient's smoking history and progressive symptoms.
Question 6 of 9
Which of the following factors should a nurse consider when assessing a patient's risk for developing pressure ulcers?
Correct Answer: A
Rationale: The correct answer is A: Patient's age and mobility. Age and mobility are key factors in pressure ulcer development as elderly and immobile patients are at higher risk due to decreased circulation and pressure on skin. Family medical history (B) is not directly linked to pressure ulcers. Frequency of hospital visits (C) is not a determining factor, and patient's education level (D) does not directly impact pressure ulcer risk. In summary, assessing age and mobility helps identify high-risk patients for developing pressure ulcers.
Question 7 of 9
What is the most appropriate action for a nurse when caring for a client with severe hypothermia?
Correct Answer: A
Rationale: The correct answer is A: Administer warm IV fluids. This is because in severe hypothermia, the body's core temperature drops dangerously low, leading to decreased circulation and potential organ failure. Administering warm IV fluids helps to gradually raise the core temperature and prevent further complications. Choice B (Warming the client with a heating pad) can cause rewarming shock and skin burns. Choice C (Placing the client in a supine position) is not directly related to treating hypothermia. Choice D (Administering analgesics) is not the priority in treating severe hypothermia.
Question 8 of 9
The nurse is performing an assessment on a 21-year-old patient and notes that his nasal mucosa appears pale, grey, and swollen. What would be the most appropriate question to ask the patient?
Correct Answer: A
Rationale: The correct answer is A: "Are you aware of having any allergies?" This question is appropriate because the patient's symptoms of pale, grey, and swollen nasal mucosa suggest an allergic reaction. By asking about allergies, the nurse can gather important information to determine the cause of the symptoms. B: "Do you have an elevated temperature?" - This question is not directly related to the patient's nasal symptoms and does not address the likely allergic reaction. C: "Have you had any symptoms of a cold?" - While cold symptoms may present similarly to allergies, the patient's specific symptoms of pale, grey, and swollen nasal mucosa are more indicative of an allergic reaction. D: "Have you been having frequent nosebleeds?" - This question does not directly address the patient's current symptoms and is not likely related to the nasal mucosa appearance described.
Question 9 of 9
The nurse suspects that a patient has hyperthyroidism, and laboratory data also indicate that the patient's T and T hormone levels are elevated. Which of the following would the nurse most likely find on 4 3 examination?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A (Tachycardia) is correct: 1. Hyperthyroidism leads to increased production of thyroid hormones. 2. Thyroid hormones can increase metabolic rate and heart rate. 3. Tachycardia is a common symptom of hyperthyroidism due to increased metabolic demand. 4. Therefore, the nurse would most likely find tachycardia on examination in a patient with hyperthyroidism. Summary of why other choices are incorrect: B: Constipation - Constipation is more commonly associated with hypothyroidism, not hyperthyroidism. C: Rapid dyspnea - Dyspnea (shortness of breath) is not a typical symptom of hyperthyroidism. D: Atrophied, nodular thyroid - Hyperthyroidism often presents with an enlarged, not atrophied, thyroid gland due to overactivity. Nodules may be present in conditions like thyroid cancer, but not specific to hyper