ATI RN
test bank for health assessment Questions
Question 1 of 5
What is the primary action when a client with a history of asthma develops wheezing?
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. When a client with asthma develops wheezing, the primary action is to administer bronchodilators to help dilate the airways and improve breathing. This helps relieve the symptoms of wheezing and prevent further complications. Providing pain relief (Choice B) is not the primary action for wheezing in asthma. Encouraging deep breathing (Choice C) may worsen the wheezing in an asthma attack. Performing chest physiotherapy (Choice D) is not the first-line treatment for wheezing in asthma.
Question 2 of 5
What is the priority nursing action for a client who is receiving blood transfusion and develops a fever?
Correct Answer: A
Rationale: Step 1: Stop the transfusion - Febrile reaction can indicate a transfusion reaction, so stopping the transfusion is crucial. Step 2: Administer antipyretics - To reduce fever and prevent further complications. Step 3: Assess for other signs of transfusion reaction - Such as chills, rash, or hypotension. Summary: Option A is correct as it addresses the immediate need to stop the transfusion and manage the fever. Options B, C, and D do not prioritize stopping the transfusion, which is crucial in this scenario.
Question 3 of 5
What should the nurse do when caring for a client who is experiencing an anaphylactic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it helps to quickly reverse severe symptoms by constricting blood vessels and opening airways. Administering corticosteroids (B) is not the immediate priority. Placing the client on their side (C) is important to prevent aspiration but does not address the anaphylactic reaction. Monitoring blood pressure (D) is essential but administering epinephrine takes precedence in managing anaphylaxis.
Question 4 of 5
What is the most important nursing action for a client who has a history of seizures?
Correct Answer: A
Rationale: The correct answer is A: Administer antiepileptic drugs. This is the most important nursing action for a client with a history of seizures because antiepileptic drugs help prevent or reduce the frequency and severity of seizures. By ensuring the client receives their prescribed medication, the nurse can help manage the condition effectively. Placing the client on their side (B) is important to prevent aspiration if a seizure occurs, but administering antiepileptic drugs is more crucial for long-term management. Checking the airway (C) is important during and after a seizure but does not address the underlying cause. Monitoring for hypoglycemia (D) is important as a potential trigger for seizures, but administering antiepileptic drugs takes precedence in managing the condition.
Question 5 of 5
What is the priority nursing intervention for a client with a deep wound infection?
Correct Answer: B
Rationale: The correct answer is B: Apply sterile dressings. This is the priority nursing intervention for a client with a deep wound infection because it helps prevent further contamination and promotes wound healing. Sterile dressings create a barrier against external pathogens and keep the wound environment clean, which is crucial in managing infections. Administering IV antibiotics (choice A) may be necessary but treating the wound first is essential. Applying heat to the wound (choice C) can worsen the infection by promoting bacterial growth. Administering IV fluids (choice D) may be needed for hydration but is not the priority in managing a deep wound infection.