ATI RN
health assessment test bank jarvis Questions
Question 1 of 5
What is the first intervention when a client is showing signs of shock after surgery?
Correct Answer: B
Rationale: The correct answer is B: Monitor for arrhythmias. This is because in a client showing signs of shock after surgery, the priority is to assess for any cardiac complications such as arrhythmias, which can be life-threatening. Monitoring for arrhythmias allows prompt identification and intervention. Administering a blood transfusion (A) may be necessary in some cases of shock but is not the first intervention. Administering oxygen (C) may also be necessary, but addressing cardiac complications takes precedence. Encouraging deep breathing (D) is not a priority in managing shock-related complications.
Question 2 of 5
What should the nurse do first when caring for a client with a suspected spinal cord injury?
Correct Answer: A
Rationale: The correct answer is A: Immobilize the spine. This is the first priority because it helps prevent further injury to the spinal cord. By immobilizing the spine, the nurse ensures that any movement doesn't worsen the existing injury. Placing the client in a supine position (B) can be done after immobilization. Administering analgesics (C) should not be done before assessing the extent of the injury. Assessing the airway (D) is important but should come after immobilizing the spine to prevent any unnecessary movement.
Question 3 of 5
What is the most effective action when a client presents with acute shortness of breath and a history of COPD?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.
Question 4 of 5
What is the nurse's priority when caring for a client with respiratory distress?
Correct Answer: C
Rationale: The correct answer is C: Placing the client on their back. This is the priority because it helps optimize the client's breathing mechanics by maximizing lung expansion. By positioning the client on their back, it allows for better oxygenation and ventilation. Administering oxygen (A) and albuterol (B) can be important interventions but positioning comes first. Placing the client on their back also helps prevent aspiration and facilitates airway clearance. Encouraging deep breathing (D) is beneficial, but if the client is in respiratory distress, ensuring proper positioning takes precedence over deep breathing exercises.
Question 5 of 5
What is the most important intervention for a client with acute pancreatitis?
Correct Answer: D
Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.