ATI RN
test bank for health assessment Questions
Question 1 of 5
What is the most important priority for a nurse caring for a client with pneumonia?
Correct Answer: D
Rationale: The correct answer is D: Administer diuretics. The priority for a nurse caring for a client with pneumonia is to maintain adequate oxygenation and prevent respiratory failure. Diuretics help reduce fluid overload in the lungs, improving gas exchange and oxygenation. Administering antibiotics (choice A) is important to treat the infection but not the top priority. Administering oxygen (choice B) is crucial for oxygenation, but diuretics take precedence to improve lung function. Administering corticosteroids (choice C) may be considered in certain cases to reduce inflammation, but it is not the primary priority.
Question 2 of 5
What should the nurse do first for a client who is post-operative and experiencing confusion?
Correct Answer: B
Rationale: The correct answer is B: Place in a safe environment. This is the first priority to ensure the safety of the confused post-operative client. Placing the client in a safe environment prevents harm from falls or accidents. Reorienting the client (choice A) can come after ensuring safety. Administering pain relief (choices C and D) should be done based on assessment but is not the first priority when the client is confused.
Question 3 of 5
What interventions should a nurse perform when a client is having difficulty walking due to a foot mass?
Correct Answer: D
Rationale: The correct answer is D (Morton's neuroma) because interventions for difficulty walking due to a foot mass include recommending proper footwear, orthotic devices, corticosteroid injections, physical therapy, and in severe cases, surgical removal of the mass. Morton's neuroma causes pain and tingling in the ball of the foot, leading to difficulty walking. Plantar fasciitis (A), Hallux valgus (B), and Hammertoe (C) do not typically present with a mass in the foot causing difficulty walking.
Question 4 of 5
What is the most important action when caring for a client on intravenous heparin?
Correct Answer: A
Rationale: The correct answer is A: Monitor aPTT levels. This is crucial in intravenous heparin therapy to ensure the therapeutic range is maintained for anticoagulation without causing bleeding. Monitoring aPTT helps adjust heparin dosage to prevent clot formation or excessive bleeding. B: Monitoring for bleeding is important but not the most important action compared to monitoring aPTT levels for appropriate dosing. C: Checking platelet count is important for some anticoagulants like heparin, but aPTT monitoring is more directly related to heparin's anticoagulant effect. D: Administering a heparin antidote (protamine sulfate) is necessary in case of heparin overdose or in emergency situations but is not the primary action in routine care.
Question 5 of 5
What do nursing activities that promote health and prevent disease accomplish? (Select one that doesn't apply)
Correct Answer: D
Rationale: The correct answer is D: Create home care safety. Nursing activities that promote health and prevent disease focus on educating individuals on maintaining their health and preventing diseases, rather than specifically creating home care safety. The other choices (A, B, C) are correct as they accurately reflect the goals of nursing activities - reducing disease risk, maintaining optimal functioning, and reinforcing good habits to promote overall health and well-being. Choice D is incorrect because while ensuring home care safety is important, it is not the primary focus of nursing activities aimed at health promotion and disease prevention.
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