ATI RN
hesi health assessment test bank 2023 Questions
Question 1 of 5
What is the priority action for a client with an open chest wound?
Correct Answer: A
Rationale: The correct answer is A: Apply a sterile dressing. Firstly, cover the wound with a sterile occlusive dressing to prevent air from entering the pleural space, reducing the risk of tension pneumothorax. This also helps to prevent infection and further complications. Administering morphine (B) or nitroglycerin (D) is not the priority in this situation as managing the chest wound is crucial. Applying an airtight dressing (C) may lead to tension pneumothorax if not done properly. Therefore, the immediate action should be to apply a sterile dressing to stabilize the wound and prevent further complications.
Question 2 of 5
What is the most appropriate intervention for a client with a severe burn?
Correct Answer: D
Rationale: The correct answer is D: Cover the burn site with a clean, dry dressing. This intervention helps protect the burn from infection, promotes healing, and reduces pain. Ice can further damage the skin. Pain medication may be needed but does not address wound care. Maintaining a sterile dressing is crucial, but covering with a clean, dry dressing is more practical and achievable in most settings.
Question 3 of 5
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. This is the priority intervention as it helps prevent complications such as blood clots and pneumonia, promotes circulation, and aids in faster recovery. Ambulation also helps maintain joint mobility and muscle strength. Administering pain medications (B) is important but not the priority. Providing wound care (C) and monitoring for infection (D) are important, but ambulation takes precedence in preventing complications.
Question 4 of 5
Which areas are most important to address for a client in Buck's traction?
Correct Answer: C
Rationale: Step 1: Nutrition is important for healing and energy. Step 2: Elimination is crucial for bowel and bladder function. Step 3: Comfort ensures the client's well-being. Step 4: Safety prevents complications. Step 5: ROM exercises can prevent muscle atrophy. Step 6: Transportation and isotonic exercises are not immediate priorities.
Question 5 of 5
A nurse is caring for a patient who has been prescribed warfarin. The nurse should monitor the patient for signs of which of the following?
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Warfarin is an anticoagulant medication that works by inhibiting blood clotting factors. Monitoring for signs of bleeding is crucial as warfarin increases the risk of bleeding events. Signs of bleeding may include easy bruising, nosebleeds, blood in urine or stool. Hypertension (B), hyperglycemia (C), and hypokalemia (D) are not direct effects of warfarin. Monitoring for these conditions may be important for other medications or conditions, but they are not the primary concern when a patient is prescribed warfarin.