ATI RN
health assessment test bank jarvis Questions
Question 1 of 5
What is the most effective action when caring for a client who is at risk of developing pressure ulcers?
Correct Answer: A
Rationale: The correct answer is A: Turn the client every two hours. This action helps prevent pressure ulcers by relieving pressure on specific areas of the body. Turning the client redistributes pressure, promotes circulation, and reduces the risk of tissue damage. It is a crucial part of pressure ulcer prevention in immobile or bedridden patients. Increasing protein intake (B) may aid in wound healing but does not directly prevent pressure ulcers. Encouraging rest (C) may not address the root cause of pressure ulcers. Applying dressings to wounds (D) is a treatment for existing ulcers, not prevention.
Question 2 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 3 of 5
What is the most appropriate intervention for a client with shortness of breath and chest tightness?
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help to relax and open up the airways, which can alleviate shortness of breath and chest tightness in conditions like asthma or COPD. Administering oxygen (choice B) can help if the client is hypoxic, but it does not directly address the underlying airway constriction. Applying a cold compress (choice C) may provide some comfort but will not address the respiratory distress. Administering IV antibiotics (choice D) is not indicated for shortness of breath and chest tightness unless there is an underlying bacterial infection.
Question 4 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 5 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.