ATI RN
hesi health assessment test bank 2023 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
Which of the following is most likely to increase the risk of sexually transmitted diseases (STDs)?
Correct Answer: D
Rationale: The correct answer is D because all choices (A, B, and C) can increase the risk of STDs. Alcohol use can impair judgment leading to risky sexual behavior. Certain sexual practices (such as unprotected sex or having multiple partners) can directly increase the risk of STD transmission. Oral contraception does not protect against STDs, so individuals relying solely on it may still be at risk. Therefore, all of the above factors can contribute to an increased risk of contracting STDs.
Question 3 of 9
A 45-year-old man arrives at the clinic and tells the nurse that he has been experiencing severe chest pain. Upon assessment, the nurse notes that his pain radiates to his left arm. The nurse's priority action would be:
Correct Answer: B
Rationale: The correct answer is B: Assess vital signs and oxygen saturation levels. This is the priority action because the patient's symptoms suggest a possible cardiac event. Assessing vital signs and oxygen saturation levels can provide crucial information on the patient's condition and help determine the urgency of the situation. Administering pain medication (choice A) should not be done before assessing the patient's vital signs. Having the patient walk around (choice C) could worsen the situation if it is indeed a cardiac event. Ordering an EKG (choice D) is important but should come after assessing vital signs to guide further evaluation and treatment.
Question 4 of 9
The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. Which of the following would be an appropriate response?
Correct Answer: D
Rationale: The correct response is D because it encourages the mother to provide specific information about the toddler's behavior indicating pain. This helps the nurse assess the severity and nature of the earache accurately. Options A and C are dismissive and may overlook a potential health issue. Option B suggests immediate action without gathering information first, which may not be necessary.
Question 5 of 9
What should the nurse do when a client is experiencing hyperglycemia?
Correct Answer: A
Rationale: The correct answer is A, administer insulin, because hyperglycemia indicates high blood sugar levels which can be effectively lowered by administering insulin. Insulin helps to move glucose from the blood into cells for energy production. Administering fluids (B) can be helpful for dehydration, but it does not directly address the high blood sugar levels. Encouraging activity (C) may help lower blood sugar levels over time, but in the immediate situation, administering insulin is more effective. Encouraging deep breathing (D) does not directly address hyperglycemia and would not be the appropriate first step in managing this condition.
Question 6 of 9
Which nursing measure is most appropriate to meet the expected outcome of positive body image in a client with Kawasaki disease?
Correct Answer: C
Rationale: The correct answer is C: explaining progression of the disease to the client and family. This measure helps the client and family understand the disease, leading to better coping and acceptance, thus promoting a positive body image. Administering immune globulin (A) is not directly related to body image. Assessing extremities (B) and heart sounds (D) are important for monitoring the disease but do not directly impact body image.
Question 7 of 9
What is the first priority for a client with suspected sepsis?
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. In sepsis, early fluid resuscitation is crucial to prevent hypotension and organ dysfunction. IV fluids help restore perfusion and stabilize the client. Administering antibiotics (choice B) is important but comes after fluid resuscitation. Performing a blood culture (choice C) is essential but not the first priority. Performing an abdominal assessment (choice D) is not directly related to managing sepsis and should not be the initial priority.
Question 8 of 9
During assessment, the nurse notices that the skin of a patient of Asian descent is yellowish brown in colour. The skin on the hard and soft palate is, however, pink in colour. From this finding, the nurse could probably rule out:
Correct Answer: B
Rationale: The correct answer is B: Jaundice. Yellowish brown skin coloration along with pink coloration of the hard and soft palate is indicative of jaundice, a condition characterized by elevated levels of bilirubin in the blood. Bilirubin causes a yellowish discoloration of the skin but does not affect the color of the mucous membranes like the hard and soft palate. Pallor (A) refers to paleness of the skin due to decreased blood flow or anemia, not relevant in this case. Cyanosis (C) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, which is not consistent with the presented findings. Iron deficiency (D) may lead to pallor, but it does not cause yellowish brown skin coloration like jaundice.
Question 9 of 9
A nurse is caring for a patient with pneumonia. Which of the following interventions should the nurse prioritize?
Correct Answer: B
Rationale: The correct answer is B: Administering oxygen as prescribed. Oxygen therapy is a critical intervention in pneumonia to improve oxygenation and prevent hypoxia. Priority is given to interventions that address the immediate physiological needs of the patient. Encouraging fluid intake (A) is important but not as urgent as oxygen therapy. Encouraging ambulation (C) can be beneficial for overall health but may not be suitable for a patient with pneumonia. Providing pain medication (D) is important for comfort but is not the priority in this case.