ATI RN
jarvis health assessment test bank Questions
Question 1 of 5
A nurse is caring for a patient with cirrhosis. The nurse should monitor for signs of which of the following?
Correct Answer: A
Rationale: Step 1: Cirrhosis can impair the liver's ability to store glycogen and produce glucose. Step 2: Liver dysfunction can lead to hypoglycemia due to decreased glycogen stores and gluconeogenesis. Step 3: Monitoring for hypoglycemia is crucial as it can result in serious complications. Step 4: Hyperglycemia (B) is less likely in cirrhosis as the liver's ability to regulate blood sugar is impaired. Step 5: Hypokalemia (C) and hyperkalemia (D) are less directly related to cirrhosis and are not the primary concerns in this case.
Question 2 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 3 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 4 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 5 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.