ATI RN
health assessment test bank Questions
Question 1 of 5
What is the most appropriate action when a client experiences chest pain and has a history of myocardial infarction?
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the recommended initial medication for chest pain in a client with a history of myocardial infarction. It helps dilate blood vessels, improving blood flow to the heart, and reducing chest pain. Aspirin (choice B) is also usually given to reduce blood clot formation, but nitroglycerin is the priority for immediate relief. Morphine (choice C) may be used if nitroglycerin is ineffective, and beta blockers (choice D) are typically used for long-term management of heart conditions, not for immediate relief of chest pain.
Question 2 of 5
What should be the nurse's first action when caring for a client who has a suspected stroke?
Correct Answer: A
Rationale: The correct answer is A: Assess the client's airway. This is the first action because airway patency is the top priority in any emergency situation, including a suspected stroke. Ensuring the client can breathe effectively is crucial to prevent hypoxia and further complications. Administering oxygen (choice B) may be necessary after assessing the airway. Administering aspirin (choice C) should be done after a definitive diagnosis of an ischemic stroke. Performing a CT scan (choice D) is important for diagnosis but is not the first action to take in a suspected stroke scenario.
Question 3 of 5
What should be the nurse's first action for a client with a suspected myocardial infarction (MI)?
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. This is the nurse's first action for a client with a suspected MI because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can help reduce chest pain and prevent further damage to the heart muscle. Administering nitroglycerin promptly is crucial in managing an MI. Monitoring cardiac rhythm (B) and assessing the ECG (C) are important steps, but administering nitroglycerin takes precedence in addressing the client's immediate symptoms. Assisting with positioning (D) is not as urgent or directly related to managing an MI compared to administering nitroglycerin.
Question 4 of 5
What is the first intervention when a client develops symptoms of shock?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygen administration is the first intervention for shock as it helps improve oxygenation to vital organs. Lack of oxygen can worsen shock. Administering IV fluids (choice B) could be the second step to improve perfusion. Monitoring respiratory rate (choice C) is important but not the first intervention. Administering pain medication (choice D) is not a priority in managing shock.
Question 5 of 5
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.