ATI RN
hesi health assessment test bank 2023 Questions
Question 1 of 5
A nurse is caring for a patient with diabetes who is experiencing hypoglycemia. The nurse should prioritize which of the following actions?
Correct Answer: B
Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. In hypoglycemia, the priority is to raise blood glucose levels quickly to prevent complications like seizures or loss of consciousness. Fast-acting carbs like juice or glucose tablets are the first-line treatment. Administering insulin (choice A) would lower blood sugar further. Administering an oral hypoglycemic agent (choice C) takes time to work and is not suitable for emergencies. Monitoring blood pressure (choice D) is important but not the priority in this situation.
Question 2 of 5
A nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about self-management. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C because using the inhaler every time the patient feels short of breath, even without a flare-up, is not the recommended practice for managing COPD. Inhalers should be used as prescribed by the healthcare provider or only during exacerbations. Here's the rationale: 1. Using the inhaler excessively can lead to overuse of medication and potential side effects. 2. It is important for patients to differentiate between regular management and acute exacerbations. 3. Monitoring oxygen levels (choice D) is essential for COPD management. 4. Quitting smoking (choice A) and deep breathing exercises (choice B) are positive self-management strategies for COPD.
Question 3 of 5
During assessment, the nurse notices that the skin of a patient of Asian descent is yellowish brown in colour. The skin on the hard and soft palate is, however, pink in colour. From this finding, the nurse could probably rule out:
Correct Answer: B
Rationale: The correct answer is B: Jaundice. Yellowish brown skin coloration along with pink coloration of the hard and soft palate is indicative of jaundice, a condition characterized by elevated levels of bilirubin in the blood. Bilirubin causes a yellowish discoloration of the skin but does not affect the color of the mucous membranes like the hard and soft palate. Pallor (A) refers to paleness of the skin due to decreased blood flow or anemia, not relevant in this case. Cyanosis (C) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, which is not consistent with the presented findings. Iron deficiency (D) may lead to pallor, but it does not cause yellowish brown skin coloration like jaundice.
Question 4 of 5
What is the most appropriate intervention for a client with acute renal failure?
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. In acute renal failure, maintaining adequate hydration is crucial to support kidney function and prevent further damage. IV fluids help improve renal perfusion and promote urine output. Hemodialysis may be necessary in severe cases but initial intervention is fluid resuscitation. Administering pain relief or morphine is not the priority in acute renal failure as addressing hydration status takes precedence over pain management.
Question 5 of 5
Which electrolyte is lost with intestinal suctioning in a client with an ileus?
Correct Answer: D
Rationale: The correct answer is D: sodium chloride. Intestinal suctioning in a client with an ileus leads to loss of fluids rich in sodium chloride. This loss can result in electrolyte imbalances and dehydration. Calcium (A), magnesium (B), and potassium (C) are not typically lost in significant amounts through intestinal suctioning in the context of an ileus. Therefore, sodium chloride is the most likely electrolyte to be lost in this scenario.