ATI RN
health assessment test bank jarvis Questions
Question 1 of 9
What is the most important intervention for a client with acute myocardial infarction (MI)?
Correct Answer: A
Rationale: The correct answer is A: Administer aspirin. Aspirin is crucial for a client with acute MI as it helps prevent further blood clot formation by inhibiting platelet aggregation, reducing chances of additional cardiac events. Oxygen (B) is not routinely recommended unless hypoxemia is present. Morphine (C) can mask symptoms and delay treatment. Nitroglycerin (D) is used to relieve chest pain but may not be the most important intervention in acute MI. Administering aspirin promptly is vital to improve outcomes and reduce mortality in acute MI cases.
Question 2 of 9
What does the Health Insurance Portability and Accountability Act (HIPAA) regulate?
Correct Answer: B
Rationale: The correct answer is B because HIPAA regulates the privacy and security of protected health information. This includes how healthcare providers, insurers, and other entities handle and safeguard patient information to ensure confidentiality. Choice A is incorrect as HIPAA does not dictate who provides client care. Choice C is incorrect as HIPAA focuses on the protection of health information, not how insurance information is obtained. Choice D is incorrect as HIPAA does not specify where a chart can be stored, but rather how the information within it is protected.
Question 3 of 9
What is the best intervention for a client who is vomiting after surgery?
Correct Answer: D
Rationale: The correct answer is D: Administer morphine. The rationale is that vomiting after surgery can be a side effect of pain medication such as morphine. By administering morphine, the pain is reduced, which can help alleviate the vomiting. This intervention targets the root cause of the vomiting. Other choices are incorrect because: A: Administering antiemetics may help with nausea but does not address the underlying cause of vomiting. B: Placing the client in a supine position may worsen vomiting due to increased abdominal pressure. C: Encouraging deep breathing may help with relaxation but does not directly address the vomiting caused by pain.
Question 4 of 9
What is the most important intervention for a client experiencing an allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis, a severe allergic reaction. It works by constricting blood vessels, increasing heart rate, and opening airways, which can reverse the life-threatening effects of an allergic reaction. Antihistamines (B) may help with mild symptoms but are not sufficient for severe reactions. Corticosteroids (C) are used to reduce inflammation but work too slowly for immediate relief. Beta-blockers (D) can worsen allergic reactions by blocking the effects of epinephrine.
Question 5 of 9
What is the most appropriate intervention for serosanguineous drainage after cholecystectomy?
Correct Answer: C
Rationale: Rationale: C: Reinforce the dressing is the correct intervention for serosanguineous drainage after cholecystectomy. This helps maintain a clean and dry wound environment, promotes healing, and prevents infection. Changing the dressing (B) may disrupt the wound healing process. Notifying the physician (A) is important but not the immediate intervention. Applying an abdominal binder (D) is not indicated for managing serosanguineous drainage.
Question 6 of 9
A nurse is teaching a patient about managing diabetes. Which of the following actions would the nurse emphasize as most important in preventing complications from diabetes?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Monitoring blood glucose levels regularly allows for timely adjustments in treatment. 2. It helps in preventing hypoglycemia or hyperglycemia complications. 3. Enables the patient to understand how their lifestyle choices impact their blood sugar levels. 4. Empowers the patient to make informed decisions regarding their diabetes management. Summary of why the other choices are incorrect: B: Limiting physical activity can lead to complications like obesity and decreased insulin sensitivity. C: Diet should focus on balanced nutrition, not just low-fat or high-protein, to manage diabetes effectively. D: Taking insulin regardless of blood sugar levels can result in hypoglycemia or poor blood sugar control.
Question 7 of 9
A patient is describing his symptoms to the nurse. Which of the following statements is a description of the setting of his symptoms?
Correct Answer: D
Rationale: The correct answer is D because it describes the setting of the symptoms by specifying when the pain occurs (every time the patient sits down to use the computer). This detail helps identify possible triggers or patterns associated with the pain. Choices A, B, and C focus on the nature or characteristics of the pain rather than the setting, making them incorrect. Choice A describes the type of pain, choice B includes associated symptoms, and choice C reflects the patient's interpretation of the pain, none of which directly address the setting of the symptoms.
Question 8 of 9
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.
Question 9 of 9
A man has been admitted to the observation unit after having been treated for a large cut on his foreheaAs the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, "I quit smoking after my wife died 7 years ago." However, the nurse notices an open packet of cigarettes in his shirt pocket. If using confrontation as a response, the nurse could say:
Correct Answer: D
Rationale: The correct answer is D because using confrontation in this situation involves addressing the discrepancy between the patient's statement and observed behavior without being aggressive or judgmental. By stating, "Mr. K., I know that you are lying," the nurse directly addresses the inconsistency, encouraging honesty and open communication. This approach can help build trust and facilitate a more honest discussion about the patient's tobacco use. Choice A is incorrect as it is too direct and may come across as accusatory. Choice B is also incorrect as it does not acknowledge the discrepancy and may not lead to a productive conversation. Choice C is incorrect as it avoids addressing the issue and focuses on the patient's personal situation instead of the behavior in question.