ATI RN
jarvis health assessment test bank Questions
Question 1 of 5
What is the priority action when a client with a history of seizures experiences one?
Correct Answer: B
Rationale: The correct answer is B: Place in a safe environment. This is the priority action because it ensures the client's safety by preventing injury during the seizure. Placing the client in a safe environment involves removing any objects that could harm them, such as sharp objects or furniture. Positioning on their side (choice A) is important after the seizure to prevent aspiration. Applying warm compresses (choice C) is not indicated during a seizure. Inserting an oral airway (choice D) is not recommended as it can be dangerous during a seizure and should only be done if the client is not breathing after the seizure.
Question 2 of 5
What should be the nurse's first action when caring for a client with suspected meningitis?
Correct Answer: A
Rationale: The correct answer is A: Perform a lumbar puncture. This is the first action because diagnosing meningitis requires cerebrospinal fluid analysis obtained through a lumbar puncture. It helps identify the specific type of meningitis (bacterial, viral, or fungal) and guides appropriate treatment. Administering pain relief (B) or oxygen (C) may be necessary but not the initial priority. Administering antibiotics (D) should be based on the results of the lumbar puncture to ensure targeted therapy.
Question 3 of 5
What should the nurse do when a client presents with a severe allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. In severe allergic reactions, such as anaphylaxis, epinephrine is the first-line treatment as it rapidly reverses life-threatening symptoms like airway constriction and low blood pressure. Antihistamines (choice B) may help with mild symptoms but are not sufficient for severe reactions. Applying a cold compress (choice C) is not effective in treating anaphylaxis. Encouraging deep breathing (choice D) is not appropriate as the client may have difficulty breathing due to airway constriction. Administering epinephrine is crucial to quickly stabilize the client's condition in a severe allergic reaction.
Question 4 of 5
What is the priority intervention when a client is experiencing respiratory distress?
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. When a client is experiencing respiratory distress, the priority intervention is to open up the airways to improve breathing. Bronchodilators help relax and widen the airways, making it easier for the client to breathe. This intervention addresses the immediate need for improved respiratory function. Administering corticosteroids (choices B and C) may be beneficial in some cases but is not the priority in acute respiratory distress. Monitoring respiratory rate (choice D) is important but does not directly address the underlying issue of airway constriction in respiratory distress.
Question 5 of 5
What is the most appropriate intervention for a client with suspected deep vein thrombosis (DVT)?
Correct Answer: A
Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants are crucial in treating DVT as they prevent blood clots from getting larger and stop new clots from forming. They help reduce the risk of complications like pulmonary embolism. Administering analgesics (B) may help with pain but does not address the root cause. Diuretics (C) are used to treat conditions like fluid retention, not DVT. Applying a warm compress (D) can actually worsen DVT by promoting blood flow. Anticoagulants are the gold standard treatment for DVT.