ATI RN
jarvis health assessment test bank Questions
Question 1 of 5
What is the most appropriate intervention for a client experiencing a heart attack?
Correct Answer: A
Rationale: Administering aspirin is the most appropriate intervention for a client experiencing a heart attack. Aspirin helps prevent blood clot formation, which is crucial in reducing further damage to the heart during a heart attack. It inhibits platelets from clumping together, improving blood flow to the heart muscle. Thrombolytics are used to dissolve existing blood clots, but aspirin is more preventive. Monitoring for arrhythmias is important but not the initial intervention. Administering morphine can be considered for pain relief but is not as crucial as administering aspirin to prevent further clot formation.
Question 2 of 5
What is the priority action when a client with a history of seizures experiences one?
Correct Answer: B
Rationale: The correct answer is B: Place in a safe environment. This is the priority action because it ensures the client's safety by preventing injury during the seizure. Placing the client in a safe environment involves removing any objects that could harm them, such as sharp objects or furniture. Positioning on their side (choice A) is important after the seizure to prevent aspiration. Applying warm compresses (choice C) is not indicated during a seizure. Inserting an oral airway (choice D) is not recommended as it can be dangerous during a seizure and should only be done if the client is not breathing after the seizure.
Question 3 of 5
What should be the nurse's first action when a client develops chest pain after surgery?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. The first action should be to ensure the client's oxygenation as chest pain could indicate decreased oxygen supply. Administering oxygen helps improve oxygen levels and can be crucial in managing potential complications. Summary of other choices: B: Administering morphine may mask the pain but doesn't address the underlying issue. C: Administering anticoagulants is not appropriate as the cause of chest pain is not related to clotting. D: Applying a warm compress is not indicated and may delay proper assessment and intervention for the chest pain.
Question 4 of 5
What should be the nurse's first action when caring for a client with suspected meningitis?
Correct Answer: A
Rationale: The correct answer is A: Perform a lumbar puncture. This is the first action because diagnosing meningitis requires cerebrospinal fluid analysis obtained through a lumbar puncture. It helps identify the specific type of meningitis (bacterial, viral, or fungal) and guides appropriate treatment. Administering pain relief (B) or oxygen (C) may be necessary but not the initial priority. Administering antibiotics (D) should be based on the results of the lumbar puncture to ensure targeted therapy.
Question 5 of 5
What should the nurse do when a client presents with a severe allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. In severe allergic reactions, such as anaphylaxis, epinephrine is the first-line treatment as it rapidly reverses life-threatening symptoms like airway constriction and low blood pressure. Antihistamines (choice B) may help with mild symptoms but are not sufficient for severe reactions. Applying a cold compress (choice C) is not effective in treating anaphylaxis. Encouraging deep breathing (choice D) is not appropriate as the client may have difficulty breathing due to airway constriction. Administering epinephrine is crucial to quickly stabilize the client's condition in a severe allergic reaction.