ATI LPN
Health Assessment in Nursing Practice Questions Questions
Question 1 of 5
A patient admitted to the hospital in hypertensive crisis is ordered to receive hydralazine (Apresoline) 20 mg IV stat for blood pressure greater than 190/100 mmHg. The best response of the nurse to this order is to:
Correct Answer: B
Rationale: The order specifies hydralazine ‘stat’ for BP >190/100 mmHg, meaning the nurse should administer it only if the BP exceeds this threshold (B). Immediate administration (A) ignores the condition, calling the physician (C) is unnecessary as the order is clear, and repeating (D) requires further orders.
Question 2 of 5
The nurse is caring for a client diagnosed with a stroke. Because of the stroke, the client has dysphagia (difficulty swallowing). Which intervention by the nurse is best for preventing aspiration?
Correct Answer: A
Rationale: High Fowler’s position (A) uses gravity to aid swallowing and prevent aspiration in dysphagia. Mixing liquids and solids (B), thinning liquids (C), or using the affected side (D) increases aspiration risk.
Question 3 of 5
Which is the primary consideration when preparing to administer thrombolytic therapy to a patient who is experiencing an acute myocardial infarction (MI)? (HAAD 2014)
Correct Answer: D
Rationale: Time since symptom onset (D) is critical for thrombolytic therapy, effective within 12 hours of MI onset. History (A), aspirin sensitivity (B), and MI specifics (C) are secondary.
Question 4 of 5
A client with a fluid volume deficit is receiving an I.V. infusion of dextrose 5% in water and lactated Ringer’s solution at 125 ml/hour. Which data collection finding indicates the need for additional I.V. fluids?
Correct Answer: D
Rationale: Dark amber urine (D) indicates concentrated urine from dehydration, suggesting more fluids are needed. Sodium 135 (A) is normal, 99.6°F (B) is mildly elevated, and neck vein distension (C) suggests fluid overload.
Question 5 of 5
Chronic alcoholic’s needs which of the following vitamins
Correct Answer: A
Rationale: Chronic alcoholics need thiamine (A) to prevent Wernicke’s encephalopathy due to poor absorption and diet. Other vitamins (B, C, D) are less critical acutely.