ATI RN
hesi health assessment test bank Questions
Question 1 of 5
What is the priority nursing action when a client experiences a severe allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it acts quickly to reverse symptoms like airway swelling and low blood pressure. It helps to open airways and increase blood pressure. Antihistamines (B) are not as fast-acting as epinephrine in severe reactions. Applying a cold compress (C) is not effective in treating anaphylaxis. Placing the client in a supine position (D) can worsen breathing difficulties. Administering epinephrine is crucial in managing severe allergic reactions promptly and effectively.
Question 2 of 5
What is the priority action for a client who has just undergone a craniotomy?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. After a craniotomy, the client may experience decreased oxygen levels due to the surgical procedure, anesthesia, or potential complications. Administering oxygen helps ensure adequate oxygenation to the brain and tissues. Placing the client in a supine or Trendelenburg position can increase intracranial pressure, which is contraindicated post-craniotomy. Monitoring for arrhythmias is important, but ensuring oxygenation takes precedence as hypoxia can have immediate detrimental effects on brain function.
Question 3 of 5
What should the nurse do first when a client develops a fever postoperatively?
Correct Answer: A
Rationale: The correct answer is A: Administer antipyretics. The nurse should first address the fever to prevent potential complications. Antipyretics help reduce fever and discomfort quickly. Monitoring vital signs (B) is important but treating the fever takes precedence. Administering fluids (C) is essential, but addressing the fever is the priority. Administering IV antibiotics (D) may be necessary if the fever is due to infection, but confirming the cause and starting treatment can come after addressing the fever.
Question 4 of 5
What is the priority nursing action for a client with a history of seizures?
Correct Answer: A
Rationale: The correct answer is A: Administer antiepileptics. Administering antiepileptics is the priority nursing action for a client with a history of seizures to prevent seizure recurrence. Antiepileptics help control and manage seizure activity effectively. Monitoring vital signs (B) and placing the client in a lateral position (C) are important actions during a seizure but are not the priority over administering antiepileptics. Providing seizure precautions (D) is also important but does not directly address the immediate need of administering antiepileptics to prevent a seizure.
Question 5 of 5
What is the priority nursing action for a client who is vomiting post-surgery?
Correct Answer: A
Rationale: Correct Answer: A - Administer antiemetics Rationale: The priority nursing action for a client vomiting post-surgery is to administer antiemetics to control nausea and vomiting, preventing complications like dehydration and electrolyte imbalance. Antiemetics help the client feel more comfortable and promote recovery. Administering fluids (choices B and C) is important, but addressing the vomiting itself takes precedence. Pain relief (choice D) is essential, but not the priority in this case.