ATI RN
health assessment in nursing test bank Questions
Question 1 of 9
A nurse is caring for a patient with a history of diabetes. The nurse should monitor for signs of which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. Patients with diabetes are at risk for high blood sugar levels. Monitoring for hyperglycemia is crucial to prevent complications like diabetic ketoacidosis. Hypoglycemia (B) is low blood sugar, dehydration (C) is not directly related to diabetes unless it causes hyperosmolar hyperglycemic state, and hypotension (D) is low blood pressure, which is not a common complication of diabetes. Regular monitoring for hyperglycemia helps in preventing diabetic complications.
Question 2 of 9
A nurse is caring for a patient who is post-operative following hip replacement surgery. Which of the following should be included in the nursing care plan to prevent complications?
Correct Answer: C
Rationale: The correct answer is C because monitoring the patient for signs of infection and deep vein thrombosis is crucial in preventing complications post-hip replacement surgery. Infections can lead to serious complications, while deep vein thrombosis can result in blood clots that can be life-threatening. By closely monitoring for these signs, the nurse can intervene early and prevent further complications. Choice A is incorrect because complete avoidance of physical activity can lead to other complications such as muscle atrophy and delayed recovery. Choice B is incorrect because pain management should be proactive to prevent unnecessary suffering. Choice D, while important, is not directly related to preventing complications such as infection and deep vein thrombosis.
Question 3 of 9
While auscultating for heart sounds, the nurse hears an unfamiliar sounWhat should the nurse do next?
Correct Answer: A
Rationale: The correct answer is A: Document the findings on the patient's record. This is the appropriate action because documenting the unfamiliar sound ensures that the information is accurately recorded for future reference. Waiting 10 minutes (B) may not address the issue, as the sound could still be present. Asking another nurse to double-check (C) may lead to subjective interpretations. Asking the patient to take deep breaths (D) may not be relevant to identifying the unfamiliar sound. Recording the finding is crucial for tracking changes in the patient's condition and communicating with other healthcare professionals.
Question 4 of 9
During an interview, the nurse asks the patient to tell more about their shortness of breath. What is the verbal skill used?
Correct Answer: D
Rationale: The correct answer is D: Open-ended question. This verbal skill allows the patient to provide detailed information and express their feelings freely. By asking the patient to talk more about their shortness of breath, the nurse encourages a comprehensive response. Reflection (A) involves paraphrasing the patient's words, not eliciting more information. Facilitation (B) involves encouraging the patient to continue but does not necessarily prompt open-ended responses. Direct question (C) typically elicits a specific answer and limits the patient's response.
Question 5 of 9
A nurse is teaching a patient with diabetes about self-management. Which of the following statements by the patient indicates the need for further education?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Taking insulin only when blood sugar is high can lead to uncontrolled levels. 2. Regular insulin dosing is essential for diabetes management. 3. Monitoring blood sugar regularly helps in adjusting insulin doses. 4. Eating a balanced diet and exercising are key components of diabetes management. 5. Reporting signs of infection is crucial due to diabetes-related complications.
Question 6 of 9
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Administering supplemental oxygen as needed. This is the priority intervention for a patient with COPD because it helps improve oxygenation and relieve respiratory distress, which is the main concern in COPD. Supplemental oxygen also helps reduce the workload on the heart and other organs. Encouraging physical activity (B) is important for overall health but may not be the priority in acute exacerbations. Administering antibiotics regularly (C) is not necessary unless there is a documented infection. Providing increased fluid intake (D) is important for maintaining hydration but is not the priority intervention in this case.
Question 7 of 9
A nurse is about to perform an assessment of a patient's lungs. Which of the following is the most appropriate action before auscultation?
Correct Answer: D
Rationale: The correct answer is D: Ask the patient to lie flat and breathe normally. This position allows for optimal lung expansion, making it easier to hear breath sounds accurately. Asking the patient to lie flat also provides a consistent baseline for comparison across different patients. A: Asking the patient to take deep breaths before auscultation may alter their normal breathing pattern and make it difficult to assess baseline lung sounds accurately. B: Having the patient sit upright can be helpful for certain assessments, but lying flat is preferred for auscultating lung sounds. C: Examining for symmetry is important but not directly related to the optimal position for auscultation.
Question 8 of 9
The nurse notices that the patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a:
Correct Answer: D
Rationale: The correct answer is D: Papule. A papule is a solid, elevated lesion that is less than 1 cm in diameter. It is circumscribed, meaning it has well-defined borders. Papules are often associated with skin conditions like acne or insect bites. A: Bulla is a large fluid-filled blister, not a solid lesion. B: Wheal is a raised, red area of skin that is typically transient and caused by an allergic reaction. C: Nodule is a solid, elevated lesion that is greater than 1 cm in diameter, not less than 1 cm.
Question 9 of 9
A nurse is caring for a patient with a history of chronic kidney disease (CKD). The nurse should monitor for which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In CKD, kidneys struggle to excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac arrhythmias. Hypokalemia (B) is unlikely in CKD due to impaired potassium excretion. Hyperglycemia (C) is more commonly associated with diabetes rather than CKD. Hypercalcemia (D) is not a typical complication of CKD; instead, patients with CKD often experience low calcium levels.