ATI RN
advanced health assessment test bank Questions
Question 1 of 4
A nurse is caring for a patient with a history of hypertension and heart failure. The nurse should monitor for which of the following signs of worsening heart failure?
Correct Answer: B
Rationale: The correct answer is B: Swelling in the legs and shortness of breath. In heart failure, fluid can build up in the body causing swelling, particularly in the legs. Shortness of breath is a common symptom due to fluid accumulation in the lungs. Increased urine output and weight loss (A) are not indicative of worsening heart failure as they suggest fluid loss. Decreased blood pressure and dizziness (C) can be seen in other conditions like dehydration. Fatigue and constipation (D) are not specific signs of heart failure worsening.
Question 2 of 4
A nurse is teaching a patient with diabetes about insulin administration. Which of the following statements by the patient indicates proper understanding?
Correct Answer: B
Rationale: The correct answer is B: I will rotate injection sites to avoid tissue damage. This statement indicates proper understanding because rotating injection sites helps prevent tissue damage and ensures consistent absorption. Injecting into the same spot every time can lead to lipohypertrophy. Injecting insulin only when blood glucose is elevated is incorrect as insulin is needed regularly. Injecting into the arm for faster absorption is also incorrect, as it can lead to unpredictable absorption rates. Rotation of sites is crucial for optimal insulin absorption and to prevent complications.
Question 3 of 4
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 4 of 4
A nurse is teaching a patient with hypertension about lifestyle modifications. Which of the following statements by the patient indicates proper understanding?
Correct Answer: D
Rationale: The correct answer is D, as limiting alcohol and reducing sodium intake are crucial lifestyle modifications for managing hypertension. Alcohol can raise blood pressure, while excess sodium can increase fluid retention and elevate blood pressure. Monitoring blood pressure regularly (choice A) is important but alone does not indicate understanding of lifestyle modifications. Taking medication as prescribed (choice B) is essential but does not address lifestyle changes. Stopping medication if blood pressure is normal (choice C) is dangerous, as hypertension often requires ongoing treatment. In summary, choice D addresses key lifestyle modifications necessary for managing hypertension, while the other choices do not fully demonstrate understanding of proper management strategies.