ATI RN
health assessment test bank Questions
Question 1 of 9
A nurse is caring for a patient who is post-operative following a lung resection. The nurse should monitor for which of the following signs of complications?
Correct Answer: A
Rationale: The correct answer is A: Increased respiratory rate and dyspnea. After a lung resection, complications like atelectasis or pneumonia can occur, leading to respiratory distress. Monitoring respiratory rate and dyspnea helps detect these issues early. Incorrect choices: B: Constipation and abdominal distension are not directly related to post-operative lung resection complications. C: Nausea and vomiting are more likely related to gastrointestinal issues rather than lung resection. D: Muscle weakness and fatigue are not specific signs of complications following a lung resection.
Question 2 of 9
Which condition is associated with inadequate intake of vitamin C?
Correct Answer: D
Rationale: The correct answer is D: Scurvy. Scurvy is caused by a deficiency in vitamin C, which is essential for collagen synthesis. Without enough vitamin C, collagen production is impaired, leading to symptoms like bleeding gums, fatigue, and joint pain. Incorrect Choices: A: Rickets is caused by a deficiency in vitamin D, not vitamin C. B: Marasmus is a severe form of malnutrition due to inadequate intake of calories and protein, not specifically vitamin C. C: Kwashiorkor is a form of severe acute malnutrition typically caused by inadequate protein intake, not vitamin C deficiency. In summary, the correct answer is D (Scurvy) because it directly relates to inadequate intake of vitamin C, while the other choices are associated with different nutrient deficiencies.
Question 3 of 9
A patient is at the clinic to have her blood pressure checkeShe has been coming to the clinic weekly since her medications were changed 2 months ago. The nurse should:
Correct Answer: A
Rationale: Rationale: 1. Collecting a follow-up database ensures up-to-date information. 2. It allows for monitoring of medication effectiveness and any new symptoms. 3. Checking the blood pressure is essential but needs current context. 4. Asking the patient to read her record may not provide all necessary updates. 5. The complete health history is crucial but obtaining it first may delay urgent blood pressure check.
Question 4 of 9
What is the most appropriate action when a client with suspected meningitis presents with a positive Brudzinski sign?
Correct Answer: D
Rationale: The correct answer is D, perform a lumbar puncture. A positive Brudzinski sign indicates meningeal irritation, a hallmark of meningitis. A lumbar puncture is the gold standard for diagnosing meningitis by analyzing cerebrospinal fluid. Placing the client on their back without proper diagnosis or treatment delays could lead to serious complications. Option B is incorrect as antibiotics should be given after confirming the diagnosis. Option C is partially correct but does not address the need for a definitive diagnostic test. Option A is incorrect as pain medication alone does not address the underlying cause of meningitis.
Question 5 of 9
Which is an inappropriate item in planning care for a severely neutropenic client?
Correct Answer: A
Rationale: The correct answer is A: Transfuse neutrophils. Neutrophil transfusion is not a standard treatment for neutropenia as neutrophils do not survive well outside the body. For the other choices: B: Excluding raw vegetables is correct to prevent infection. C: Avoiding rectal suppositories is correct to prevent mucosal injury. D: Prohibiting vases of fresh flowers is correct to prevent exposure to fungal spores. So, transfusing neutrophils is inappropriate as it is not a standard treatment for neutropenia.
Question 6 of 9
A nurse is caring for a patient with diabetes and peripheral neuropathy. The nurse should educate the patient to prioritize which of the following?
Correct Answer: A
Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for a patient with diabetes and peripheral neuropathy to prevent complications like diabetic foot ulcers. Daily foot inspections can help detect any injuries or changes early to prevent infection or further damage. It is important to prioritize this over other choices because early intervention can prevent serious consequences. Engaging in weight-bearing exercise (choice B) can be beneficial but may not be the priority in this case. Increasing protein intake (choice C) is not directly related to foot care. Using tight-fitting shoes (choice D) can lead to pressure ulcers and should be avoided.
Question 7 of 9
What is the most appropriate nursing action for a client with suspected peritonitis?
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum often caused by infection. Administering antibiotics is crucial to combat the infection. It is important to treat the underlying cause first before focusing on symptom management. Administering analgesics (B) may provide temporary relief but won't address the infection. Applying an ice pack (C) is not appropriate for peritonitis as it won't treat the infection. Performing a laparotomy (D) is a surgical procedure that may be necessary in severe cases but is not the initial nursing action.
Question 8 of 9
Which quadrant of the abdomen is tender in suspected appendicitis?
Correct Answer: C
Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.
Question 9 of 9
Which fetal heart monitor pattern can indicate cord compression?
Correct Answer: A
Rationale: The correct answer is A: variable decelerations. Variable decelerations are abrupt decreases in fetal heart rate that vary in depth, duration, and timing, which can indicate cord compression. The variability in these decelerations suggests that the umbilical cord is being compressed intermittently. Early decelerations (B) are usually caused by head compression during contractions and mirror the contractions, not indicating cord compression. Bradycardia (C) is a slow heart rate, which can be caused by various factors but is not specific to cord compression. Tachycardia (D) is a fast heart rate, which can also be caused by various factors but is not typically associated with cord compression.