ATI RN
test bank for health assessment Questions
Question 1 of 5
What is the most important action when caring for a client with fluid overload?
Correct Answer: A
Rationale: The correct answer is A: Monitor urine output. This is the most important action because it helps assess the client's fluid status and kidney function. Monitoring urine output can indicate if the client's body is effectively eliminating excess fluid. Elevating the head of the bed (B) helps with respiratory function but is not the priority in fluid overload. Administering diuretics (C) may be necessary but should be based on urine output monitoring. Encouraging deep breathing (D) is important for respiratory function but not directly related to managing fluid overload.
Question 2 of 5
What makes a focused assessment different from a comprehensive assessment?
Correct Answer: D
Rationale: A focused assessment is more in-depth on specific issues, providing detailed information on a particular problem or concern. This allows for targeted interventions and treatment strategies. In contrast, a comprehensive assessment covers the body head to toe and involves all body systems, which may not be necessary when focusing on a specific issue. Occurring only in the clinic is a limitation to choice B, as assessments can be conducted in various settings. Involving all body systems, as stated in choice C, is not the primary focus of a focused assessment.
Question 3 of 5
Which response is appropriate when a 20-year-old woman says she needs gastric bypass surgery for weight loss?
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct: 1. Empathy and respect: By saying "I respect your decision to choose surgery," you acknowledge her autonomy and decision-making. 2. Supportive approach: This response shows understanding and non-judgmental support for her choice. 3. Person-centered care: Recognizing her individual needs and choices is crucial in providing quality healthcare. Summary: A: Irrelevant and insensitive to her medical needs. B: Disregards her current situation and overlooks the complexity of weight loss. C: Implies a one-size-fits-all approach without considering her specific circumstances. D: Demonstrates respect, understanding, and support for her decision-making.
Question 4 of 5
Which sign might a nurse observe in a client with a high ammonia level?
Correct Answer: A
Rationale: The correct answer is A: coma. High ammonia levels can lead to hepatic encephalopathy, causing impaired brain function and potentially leading to coma. Edema (B) is typically associated with fluid retention, not high ammonia levels. Hypoxia (C) is a condition of low oxygen levels, not directly related to high ammonia levels. Polyuria (D) is excessive urination, which is not a common sign of high ammonia levels.
Question 5 of 5
What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36 mmHg, and HCO3 24 mEq/L?
Correct Answer: B
Rationale: The given ABG values fall within normal ranges, indicating homeostasis. The pH is within the normal range (7.35-7.45), indicating acid-base balance. The PO2 is slightly lower but still within the normal range (80-100 mmHg). PCO2 falls within the normal range (35-45 mmHg), showing effective ventilation. The HCO3 level is also within the normal range (22-26 mEq/L), indicating proper kidney function. Therefore, all values are within normal limits, reflecting a state of homeostasis. Other choices are incorrect as they suggest imbalances in acid-base status, which is not seen with these values.
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