ATI RN
test bank for health assessment Questions
Question 1 of 5
What is the most appropriate action for a nurse to take when a client's blood pressure drops significantly?
Correct Answer: A
Rationale: The correct action is to administer IV fluids when a client's blood pressure drops significantly. This helps increase blood volume and improve circulation, stabilizing the blood pressure. Administering pain medication (B) does not address the root cause of low blood pressure. Applying a heating pad (C) is not effective in treating low blood pressure. Monitoring the client's respiratory rate (D) is important but not the immediate action needed to address a significant drop in blood pressure.
Question 2 of 5
What is the primary action when a client with a history of asthma develops wheezing?
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. When a client with asthma develops wheezing, the primary action is to administer bronchodilators to help dilate the airways and improve breathing. This helps relieve the symptoms of wheezing and prevent further complications. Providing pain relief (Choice B) is not the primary action for wheezing in asthma. Encouraging deep breathing (Choice C) may worsen the wheezing in an asthma attack. Performing chest physiotherapy (Choice D) is not the first-line treatment for wheezing in asthma.
Question 3 of 5
What is the most important priority for a nurse caring for a client with pneumonia?
Correct Answer: D
Rationale: The correct answer is D: Administer diuretics. The priority for a nurse caring for a client with pneumonia is to maintain adequate oxygenation and prevent respiratory failure. Diuretics help reduce fluid overload in the lungs, improving gas exchange and oxygenation. Administering antibiotics (choice A) is important to treat the infection but not the top priority. Administering oxygen (choice B) is crucial for oxygenation, but diuretics take precedence to improve lung function. Administering corticosteroids (choice C) may be considered in certain cases to reduce inflammation, but it is not the primary priority.
Question 4 of 5
What is the priority nursing action for a client who is receiving blood transfusion and develops a fever?
Correct Answer: A
Rationale: Step 1: Stop the transfusion - Febrile reaction can indicate a transfusion reaction, so stopping the transfusion is crucial. Step 2: Administer antipyretics - To reduce fever and prevent further complications. Step 3: Assess for other signs of transfusion reaction - Such as chills, rash, or hypotension. Summary: Option A is correct as it addresses the immediate need to stop the transfusion and manage the fever. Options B, C, and D do not prioritize stopping the transfusion, which is crucial in this scenario.
Question 5 of 5
What should the nurse do when caring for a client who is experiencing an anaphylactic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it helps to quickly reverse severe symptoms by constricting blood vessels and opening airways. Administering corticosteroids (B) is not the immediate priority. Placing the client on their side (C) is important to prevent aspiration but does not address the anaphylactic reaction. Monitoring blood pressure (D) is essential but administering epinephrine takes precedence in managing anaphylaxis.