ATI RN
health assessment test bank Questions
Question 1 of 5
What is the priority nursing intervention for a client with a history of asthma experiencing wheezing?
Correct Answer: A
Rationale: The priority nursing intervention for a client with asthma experiencing wheezing is to administer oxygen. Wheezing indicates airway constriction and decreased oxygenation, making oxygen crucial for adequate tissue perfusion. Administering oxygen helps improve oxygen levels, alleviate respiratory distress, and prevent hypoxemia. Applying a bronchodilator (Choice B) may be beneficial after oxygen is administered. Applying a cold compress (Choice C) is not indicated for asthma exacerbations, and encouraging deep breathing (Choice D) may worsen respiratory distress in a client with wheezing. In summary, administering oxygen is the priority intervention to address the immediate respiratory needs of the client with asthma and wheezing.
Question 2 of 5
What is the priority nursing action for a client with a suspected stroke?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygenation is the priority in stroke management to ensure adequate oxygen supply to the brain. Oxygen therapy can help reduce hypoxia, which is crucial in the acute phase of a stroke. Administering aspirin (B) is important but comes after ensuring oxygenation. Administering thrombolytics (C) requires proper assessment and diagnostic confirmation, not an immediate priority. Placing the client in a supine position (D) may worsen stroke symptoms if there is compromised blood flow, so it is not recommended as the initial action.
Question 3 of 5
What is the most effective action for a client with suspected sepsis?
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating sepsis as they help to fight the underlying infection causing the condition. Administering antibiotics promptly can prevent the infection from spreading and worsening. Fluids (choices B and C) are important for treating sepsis to maintain blood pressure and support organ function, but antibiotics are the primary intervention to target the infection. Administering oxygen (choice D) may be necessary to support respiratory function in septic patients, but it is not the most effective action to address the underlying infection.
Question 4 of 5
What should the nurse assess first in a client with severe abdominal pain?
Correct Answer: A
Rationale: The correct answer is A: Assess vital signs. Vital signs provide crucial information on the client's overall condition and can help identify any life-threatening issues. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can guide immediate interventions and determine the urgency of further assessments or treatments. Administering oxygen (B) would be appropriate after assessing vital signs. Performing an ECG (C) may be indicated later but is not the priority in this acute situation. Monitoring serum glucose levels (D) is not typically the first assessment in a client with severe abdominal pain.
Question 5 of 5
What should be done for a client who is post-op and develops a fever within the first 48 hours?
Correct Answer: B
Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.