What is the most important intervention for a client in shock?

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Question 1 of 9

What is the most important intervention for a client in shock?

Correct Answer: A

Rationale: The correct answer is A: Administer fluids. In shock, the most crucial intervention is to restore perfusion by increasing circulating volume. Administering fluids helps to improve tissue perfusion and oxygen delivery. This is essential for stabilizing the client's condition. Monitoring cardiac rhythm (B) and blood pressure (C) are important, but addressing the underlying issue of hypovolemia by giving fluids takes precedence. Providing IV antibiotics (D) is not the primary intervention for shock, as the immediate focus should be on restoring blood flow and oxygen delivery.

Question 2 of 9

What is the most effective action when a client with acute respiratory distress syndrome (ARDS) develops hypoxemia?

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In ARDS, the primary issue is hypoxemia due to impaired gas exchange in the lungs. Administering oxygen helps to increase the oxygen levels in the blood, improving oxygenation to vital organs. Corticosteroids (B) are not indicated as they have not shown consistent benefit in ARDS treatment. Bronchodilators (C) are not effective as ARDS is not primarily a bronchoconstrictive disorder. Applying an ice pack to the chest (D) is not relevant and will not address the underlying hypoxemia. Administering oxygen is the most effective and essential intervention to correct hypoxemia in ARDS.

Question 3 of 9

A nurse is providing education to a patient with diabetes. Which of the following statements by the patient indicates the need for further education?

Correct Answer: C

Rationale: The correct answer is C because stopping insulin when blood sugar is normal can lead to hyperglycemia. Choice A shows understanding of managing diabetes. Choice B indicates monitoring blood sugar, crucial for diabetes management. Choice D demonstrates adherence to medication schedule, essential for controlling blood sugar levels. Stopping insulin prematurely can disrupt the balance and result in complications.

Question 4 of 9

Which lab values indicate a decreased risk of cardiovascular disease?

Correct Answer: A

Rationale: Step-by-step rationale: 1. High HDL cholesterol is considered beneficial as it helps remove LDL cholesterol from arteries, reducing the risk of plaque buildup. 2. Low HDL cholesterol is associated with an increased risk of cardiovascular disease. 3. Low total cholesterol may not necessarily indicate a decreased risk, as it could be due to low levels of protective HDL cholesterol. 4. Low triglycerides, while generally considered good, do not directly indicate a decreased risk of cardiovascular disease like high HDL cholesterol does. In summary, high HDL cholesterol is the correct answer as it plays a crucial role in reducing the risk of cardiovascular disease by removing LDL cholesterol, whereas the other choices do not offer the same protective benefits.

Question 5 of 9

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 6 of 9

An example of a cognition area for the mental health examination is:

Correct Answer: B

Rationale: The correct answer is B: Orientation, as it assesses a person's awareness of time, place, and person. This is crucial for evaluating cognitive functioning in mental health exams. Speech (A) is related to communication, Perception (C) involves interpreting sensory information, and Judgement (D) pertains to decision-making skills. However, in the context of a mental health examination, assessing orientation is essential for understanding a person's cognitive status and ability to interact with their environment effectively.

Question 7 of 9

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 8 of 9

A nurse is providing discharge instructions to a patient with cirrhosis. Which of the following statements by the patient indicates the need for further education?

Correct Answer: C

Rationale: The correct answer is C. Patients with cirrhosis should limit protein intake to prevent hepatic encephalopathy. Statement C indicates a need for further education as it is incorrect. A is correct as alcohol worsens cirrhosis. B is correct to manage symptoms. D is correct to monitor for fluid retention.

Question 9 of 9

Which nursing intervention is most appropriate for a client with chronic pain?

Correct Answer: B

Rationale: Correct Answer: B (Administer nonsteroidal anti-inflammatory drugs - NSAIDs) Rationale: 1. NSAIDs are commonly used for chronic pain management due to their anti-inflammatory properties. 2. NSAIDs target the underlying inflammation that often contributes to chronic pain. 3. Opioids may be reserved for severe pain due to their potential for addiction and side effects. 4. Monitoring blood pressure is important but not the primary intervention for chronic pain. 5. Acetaminophen is a mild pain reliever and may not be as effective for chronic pain compared to NSAIDs.

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