ATI RN
jarvis health assessment test bank Questions
Question 1 of 5
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following assessments?
Correct Answer: A
Rationale: The correct answer is A: Breath sounds and oxygen saturation. In COPD, monitoring respiratory status is crucial due to impaired gas exchange. Assessing breath sounds helps identify any adventitious sounds like wheezing or crackles, indicating respiratory distress. Oxygen saturation reflects oxygenation status, vital for patients with COPD prone to hypoxemia. Nutritional intake and weight (B), bowel sounds and abdominal girth (C), and urine output and skin integrity (D) are important but secondary assessments in this case. Nutritional status and weight are important for overall health, bowel sounds and abdominal girth are related to gastrointestinal function, and urine output and skin integrity are indicators of hydration and overall skin health, respectively. However, in a patient with COPD, the priority is ensuring adequate oxygenation and respiratory function.
Question 2 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 3 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 4 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.
Question 5 of 5
A nurse is caring for a patient with chronic kidney disease (CKD). The nurse should monitor for which of the following signs of complications?
Correct Answer: A
Rationale: Correct answer: A - Hyperkalemia Rationale: 1. In CKD, impaired kidney function leads to decreased potassium excretion, causing hyperkalemia. 2. Hyperkalemia can result in life-threatening cardiac arrhythmias. 3. Monitoring potassium levels is crucial in CKD management. Summary: B: Hypoglycemia - Not typically associated with CKD, more common in diabetes. C: Hyperglycemia - Common in diabetes, but not a typical complication of CKD. D: Hypercalcemia - Uncommon in CKD, more often seen in hyperparathyroidism.