ATI RN
jarvis health assessment test bank Questions
Question 1 of 5
A nurse is caring for a patient with a history of stroke. The nurse should monitor for signs of which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis. Patients with a history of stroke are at an increased risk of developing deep vein thrombosis due to immobility and vascular damage. This complication can lead to serious consequences, such as pulmonary embolism. Monitoring for signs of deep vein thrombosis, such as leg swelling and pain, is crucial for early detection and intervention. Severe dehydration (A), liver failure (C), and pulmonary embolism (D) are less likely complications in a patient with a history of stroke compared to deep vein thrombosis.
Question 2 of 5
A patient with diabetes is experiencing a diabetic foot ulcer. The nurse should prioritize which of the following interventions?
Correct Answer: C
Rationale: The correct answer is C: Assessing for signs of infection. This is the priority because diabetic foot ulcers are at high risk for infection, which can lead to serious complications. By assessing for signs of infection such as redness, warmth, swelling, pus, or foul odor, the nurse can promptly identify and initiate appropriate treatment. Administering antibiotics (A) should be based on the assessment findings. Providing pain relief (B) is important but not the priority when infection is a concern. Encouraging weight-bearing activity (D) may worsen the ulcer and should be avoided initially.
Question 3 of 5
A nurse is caring for a patient with asthma who is using a metered-dose inhaler (MDI). The nurse should instruct the patient to:
Correct Answer: D
Rationale: The correct answer is D: Hold the breath for at least 5 seconds after inhaling the medication. Holding the breath after inhaling the medication allows for better absorption of the medication into the lungs. This helps ensure the medication reaches the target area for optimal effectiveness. Exhaling deeply before using the inhaler (Choice A) is not necessary and can actually reduce the amount of medication reaching the lungs. Using the inhaler only when asthma symptoms are severe (Choice B) is not recommended as it is important to use the inhaler as prescribed by the healthcare provider. Inhaling deeply while activating the inhaler (Choice C) is important, but holding the breath after inhaling the medication is crucial for optimal medication delivery.
Question 4 of 5
A nurse is providing discharge instructions to a patient with cirrhosis. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C. Patients with cirrhosis should limit protein intake to prevent hepatic encephalopathy. Statement C indicates a need for further education as it is incorrect. A is correct as alcohol worsens cirrhosis. B is correct to manage symptoms. D is correct to monitor for fluid retention.
Question 5 of 5
A nurse is assessing a patient with a history of stroke. The nurse should prioritize monitoring for which of the following?
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and vascular damage. Monitoring for DVT is crucial to prevent life-threatening complications like pulmonary embolism. Acute renal failure (A) is not directly related to stroke and is not a common complication. Pneumonia (C) may occur but is not the highest priority compared to DVT. Hypertension (D) is important to monitor but is not the priority in this case as DVT poses a more immediate risk to the patient's health.