ATI RN
advanced health assessment test bank Questions
Question 1 of 9
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following complications?
Correct Answer: C
Rationale: The correct answer is C, hypercapnia. In COPD, impaired lung function leads to inadequate oxygen exchange, causing increased carbon dioxide levels in the blood (hypercapnia). This can result in respiratory acidosis and further exacerbate respiratory distress. Monitoring for hypercapnia is crucial in COPD management to prevent respiratory failure. Incorrect choices: A: Pulmonary embolism - While patients with COPD are at increased risk for blood clots, pulmonary embolism is not a direct complication of COPD. B: Pneumothorax - Although individuals with COPD may develop pneumothorax due to weakened lung tissue, it is not a common complication. D: Asthma attack - Asthma and COPD are distinct conditions with different pathophysiology. Asthma attacks are not a typical complication of COPD.
Question 2 of 9
A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following assessments?
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation levels. This assessment is crucial in pneumonia to ensure adequate oxygenation. Low oxygen levels can lead to respiratory distress. Pain levels (B) are important but not a priority over oxygenation. Bowel sounds (C) are not directly related to pneumonia. Level of consciousness (D) is also important but not as critical as ensuring proper oxygen levels for a patient with pneumonia. Oxygen saturation levels should be prioritized to prevent complications and ensure the patient's respiratory status is stable.
Question 3 of 9
The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has come to the clinic to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs audibly. Which of the following statements does the nurse know is most accurate, considering the concept of communication?
Correct Answer: B
Rationale: The correct answer is B because the woman's nonverbal cues (looking nervously at her hands, sighing audibly) indicate potential anxiety or stress. The nurse should acknowledge these cues and explore her feelings further to provide appropriate support. Option A is incorrect as it does not address the woman's nonverbal cues. Option C is incorrect as it assumes the woman is not genuinely excited about the pregnancy. Option D is incorrect as it overlooks the woman's nonverbal cues and does not address her potential emotional needs.
Question 4 of 9
A nurse is teaching a patient with diabetes about insulin administration. Which of the following actions should the nurse emphasize to the patient?
Correct Answer: D
Rationale: The correct answer is D: Rotate injection sites to prevent lipodystrophy. Rotating injection sites helps prevent the development of lipodystrophy, a condition characterized by the loss of fat tissue at the injection site. This is important for maintaining consistent insulin absorption and reducing the risk of injection site complications. A: Storing insulin at room temperature is generally recommended, but it is not the most critical action for insulin administration. B: Using insulin immediately after drawing it up is not necessary for all types of insulin and may not be feasible in all situations. C: Injecting insulin into the same spot can lead to tissue damage and inconsistent insulin absorption, so it should be avoided.
Question 5 of 9
The nurse is planning to assess new memory with a patient. The best way to do this would be to:
Correct Answer: C
Rationale: The correct answer is C: Give him the Four Unrelated Words Test. This is the best way to assess new memory because it is a standardized test specifically designed to evaluate a patient's ability to form new memories. The test involves presenting the patient with four unrelated words and then asking them to recall those words after a delay. This test is reliable, valid, and widely used in clinical settings to assess new memory formation. Other choices are incorrect because: A: Administering the FACT test is not the best way to assess new memory as it is not specifically designed for this purpose. B: Asking the patient to describe his first job does not directly evaluate new memory formation and may not provide a standardized assessment. D: Asking the patient to describe the last TV show he watched does not focus on new memory and is not a standardized way to assess memory function.
Question 6 of 9
Which of the following statements represents subjective data about the patient's skin?
Correct Answer: C
Rationale: The correct answer is C because it indicates that the information was provided directly by the patient and is based on their perception or feeling. Subjective data is based on the patient's experiences and cannot be observed or measured by others. Choices A, B, and D are all objective data as they can be observed or measured by healthcare providers. Choice A describes a visible characteristic of the skin, choice B indicates absence of observable lesions, and choice D reports an observed lesion on a specific location of the skin. Therefore, choice C is the only option that reflects subjective data about the patient's skin.
Question 7 of 9
A patient is diagnosed with anemia. The nurse is educating the patient about dietary sources of iron. Which of the following foods is the best source of iron?
Correct Answer: C
Rationale: The correct answer is C: Chicken liver. Chicken liver is the best source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods like spinach or oranges. Eggs do contain iron, but in smaller amounts compared to chicken liver. Oranges, on the other hand, are a source of vitamin C which can enhance iron absorption but do not contain significant amounts of iron themselves.
Question 8 of 9
Which of the following is the best indicator of a patient's nutritional status?
Correct Answer: B
Rationale: The correct answer is B: Serum albumin levels. Serum albumin is a protein produced by the liver and is a key indicator of a patient's nutritional status. Low levels of serum albumin indicate malnutrition or protein deficiency. Monitoring serum albumin levels provides an objective measure of the patient's overall nutritional status. Choice A (Patient's weight) can be influenced by factors other than nutrition, such as fluid retention or muscle mass. Choice C (Patient's food preferences) does not provide direct information on the patient's actual nutritional intake. Choice D (Number of meals consumed per day) does not account for the quality or quantity of nutrients consumed in those meals.
Question 9 of 9
A nurse is caring for a patient with a history of chronic asthma. The nurse should prioritize monitoring for which of the following complications?
Correct Answer: C
Rationale: The correct answer is C: Respiratory failure. For a patient with chronic asthma, the priority complication to monitor for is respiratory failure as it can be life-threatening. Asthma is a chronic respiratory condition that can lead to severe bronchoconstriction and impaired gas exchange, potentially resulting in respiratory failure. Monitoring for signs such as increased respiratory rate, use of accessory muscles, decreased oxygen saturation, and altered mental status is crucial. Pneumothorax (A) is a possible complication but less common in chronic asthma. Hyperglycemia (B) and chronic renal failure (D) are not directly related to asthma and are not the primary complications to monitor for in this case.