ATI RN
health assessment test bank Questions
Question 1 of 9
The major electrolytes in the extracellular fluid are:
Correct Answer: C
Rationale: The correct answer is C: sodium and chloride. In the extracellular fluid, sodium and chloride are the major electrolytes due to their roles in maintaining fluid balance, nerve function, and muscle contraction. Potassium and phosphate (choice B) are primarily found in intracellular fluid, while potassium and chloride (choice A) are not the major electrolytes in extracellular fluid. Similarly, sodium and phosphate (choice D) are not major extracellular electrolytes. Thus, choice C is the correct answer based on the significant presence and functions of sodium and chloride in the extracellular fluid.
Question 2 of 9
A nurse is caring for a patient who is post-operative following an abdominal surgery. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation to prevent deep vein thrombosis. Early ambulation helps prevent blood clot formation in the legs, reducing the risk of deep vein thrombosis post-surgery. It also promotes circulation and aids in preventing complications like pneumonia. Administering pain medication (B) is important, but preventing complications should take priority. Providing wound care (C) is essential but not the top priority. Encouraging a high-protein diet (D) is beneficial for healing, but immediate post-operative mobility is crucial for preventing complications.
Question 3 of 9
Which client must avoid foods high in potassium?
Correct Answer: D
Rationale: The correct answer is D. A client with renal disease must avoid foods high in potassium to prevent hyperkalemia, as the kidneys are unable to properly filter and excrete potassium. Foods high in potassium can lead to dangerous levels of potassium in the blood, which can be life-threatening for individuals with renal disease. Choice A is incorrect because a client receiving diuretic therapy may actually need to increase their potassium intake due to the potassium-wasting effects of diuretics. Choice B is incorrect as having an ileostomy does not necessarily affect potassium levels. Choice C is incorrect because clients with metabolic alkalosis may actually benefit from consuming foods high in potassium to help correct the acid-base imbalance.
Question 4 of 9
What is the most appropriate action when a client with suspected meningitis presents with a positive Brudzinski sign?
Correct Answer: D
Rationale: The correct answer is D, perform a lumbar puncture. A positive Brudzinski sign indicates meningeal irritation, a hallmark of meningitis. A lumbar puncture is the gold standard for diagnosing meningitis by analyzing cerebrospinal fluid. Placing the client on their back without proper diagnosis or treatment delays could lead to serious complications. Option B is incorrect as antibiotics should be given after confirming the diagnosis. Option C is partially correct but does not address the need for a definitive diagnostic test. Option A is incorrect as pain medication alone does not address the underlying cause of meningitis.
Question 5 of 9
What is the best way to assess a client's nutritional status?
Correct Answer: B
Rationale: The correct answer is B: Monitoring serum albumin levels. This is because serum albumin is a protein synthesized by the liver that reflects long-term protein intake and overall nutritional status. Low levels indicate malnutrition or inflammation. Obtaining a dietary history (choice A) is important but may not always reflect the actual nutritional status. Monitoring weight (choice C) is helpful but may not provide a comprehensive view of the client's nutritional status. Providing a meal plan (choice D) is a proactive approach but does not directly assess the client's current nutritional status.
Question 6 of 9
Which condition places a client at risk for elevated ammonia levels?
Correct Answer: D
Rationale: The correct answer is D: Lupus. Lupus can affect the kidneys, leading to renal impairment. Renal impairment can decrease the body's ability to excrete ammonia, resulting in elevated levels. Renal failure (choice A) can also lead to elevated ammonia levels, but lupus specifically contributes to renal issues. Cirrhosis (choice B) primarily affects the liver, not kidneys. Psoriasis (choice C) is a skin condition and does not directly impact ammonia levels.
Question 7 of 9
A 47-year-old woman who is a recent immigrant to Canada is being seen at the clinic today for her uncontrolled diabetes. The nurse knows that the patient lives with her husband and a large extended family. The nurse concludes that part of the patient's inability to maintain and comply with her diet and diabetic regime is the foods that this patient eats. This conclusion is an example of:
Correct Answer: D
Rationale: The correct answer is D: culturalism. The nurse's conclusion that the patient's inability to maintain her diet and diabetic regime is due to the foods she eats reflects culturalism. Culturalism refers to the belief that a person's behaviors and beliefs are solely determined by their culture. In this case, the nurse is attributing the patient's struggles solely to her cultural background without considering other factors. A: Cultural sensitivity is about being aware and respectful of different cultures, but it does not involve making assumptions based on culture alone. B: Cultural safety is about creating a safe and respectful environment for individuals from different cultures, but it does not involve making assumptions about behavior solely based on culture. C: Cultural perspective involves understanding different cultural viewpoints, but it does not involve making assumptions about behavior solely based on culture. In summary, the nurse's conclusion is an example of culturalism as it oversimplifies the patient's situation by attributing her struggles solely to her cultural background.
Question 8 of 9
Which of the following statements about the mental health examination is true?
Correct Answer: B
Rationale: The correct answer is B because the mental health examination should be integrated into the health history interview. This allows for a comprehensive understanding of the patient's mental health status. Gathering mental health information during the health history interview is crucial as it provides insight into the patient's current mental state, past history, and potential risk factors. This integrated approach is efficient and effective in assessing the patient's mental health needs. A is incorrect because while family input can be valuable, it is not always the best or only resource for information about coping skills. C is incorrect as integrating the mental health examination into the health history interview should not necessarily take an enormous amount of extra time if done efficiently. D is incorrect as a complete mental health examination may not always be necessary to assess the patient's level of functioning; integrating mental health information into the health history interview can often provide sufficient insight.
Question 9 of 9
Which intervention should be performed when assessing a client with an arteriovenous fistula (AVF) for hemodialysis?
Correct Answer: C
Rationale: Correct Answer: C - Administer IV fluids Rationale: 1. Assess patient's fluid status and hydration level. 2. IV fluids help maintain adequate hydration during hemodialysis. 3. Prevents hypotension and ensures stable blood pressure during the procedure. 4. Improves overall hemodialysis efficiency and patient safety. Summary: A: Checking patency is important, but not the primary intervention for hemodialysis. B: Monitoring for bleeding is crucial but not specific to AVF assessment. D: Applying an airtight dressing is not necessary for AVF assessment.