ATI RN
hesi health assessment test bank 2023 Questions
Question 1 of 9
What nursing interventions are important for a client in Buck's traction?
Correct Answer: C
Rationale: Step 1: Nutrition is important for overall health and healing in a client in Buck's traction. Step 2: Elimination is necessary to prevent complications such as constipation. Step 3: Comfort measures help alleviate pain and promote well-being. Step 4: Safety measures ensure the client's well-being during traction. Step 5: ROM exercises are not recommended to prevent displacement of traction. Transportation and isotonic exercises are not directly related to Buck's traction care.
Question 2 of 9
A nurse is teaching a patient with a history of hypertension about lifestyle changes. Which of the following lifestyle modifications should the nurse prioritize?
Correct Answer: B
Rationale: The correct answer is B because reducing alcohol consumption and limiting sodium intake are both crucial lifestyle modifications for managing hypertension. Alcohol can raise blood pressure, while excess sodium can contribute to hypertension. By prioritizing these changes, the patient can better control their blood pressure. Choice A is incorrect because increasing sodium intake can worsen hypertension due to fluid retention. Choice C is incorrect as decreasing physical activity can lead to weight gain and worsen hypertension. Choice D is incorrect as processed foods are often high in sodium and unhealthy fats, which can negatively impact blood pressure.
Question 3 of 9
What is the nurse's first priority when caring for a client with severe burns?
Correct Answer: B
Rationale: The correct answer is B: Administer antibiotics. When caring for a client with severe burns, the first priority is to prevent infection, which can be life-threatening. Administering antibiotics helps reduce the risk of infection. Cleansing and dressing the wounds can come after ensuring infection control. Performing a tracheostomy is not typically the first priority unless there are airway concerns. Administering analgesics is important, but it is not the first priority in this case.
Question 4 of 9
A nurse is caring for a patient with diabetes who is experiencing hypoglycemia. The nurse should prioritize which of the following actions?
Correct Answer: B
Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. In hypoglycemia, the priority is to raise blood glucose levels quickly to prevent complications like seizures or loss of consciousness. Fast-acting carbs like juice or glucose tablets are the first-line treatment. Administering insulin (choice A) would lower blood sugar further. Administering an oral hypoglycemic agent (choice C) takes time to work and is not suitable for emergencies. Monitoring blood pressure (choice D) is important but not the priority in this situation.
Question 5 of 9
A nurse is caring for a patient with a history of diabetes and peripheral neuropathy. The nurse should educate the patient to prioritize which of the following?
Correct Answer: A
Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for patients with diabetes and peripheral neuropathy to prevent complications like infections and ulcers. By inspecting their feet daily, the patient can identify any injuries or abnormalities early and seek prompt medical attention. This proactive approach can help prevent serious consequences such as amputations. Summary of incorrect choices: B: Taking medications only when experiencing symptoms - This is not recommended as medications for diabetes and neuropathy are often prescribed to prevent complications and manage the conditions on a daily basis. C: Exercising to increase foot circulation - While exercise is beneficial, patients with peripheral neuropathy may have decreased sensation in their feet, increasing the risk of injury during exercise. D: Wearing tight-fitting shoes to avoid blisters - Tight-fitting shoes can cause pressure points and increase the risk of foot injuries, especially in patients with neuropathy.
Question 6 of 9
Which assessment finding indicates a positive response to Heparin therapy?
Correct Answer: B
Rationale: The correct answer is B: increased fibrinogen. Heparin therapy works by inhibiting clot formation by enhancing the activity of antithrombin III, which leads to decreased levels of fibrinogen. Therefore, an increase in fibrinogen levels would indicate a positive response to Heparin therapy. Incorrect choices: A: increased platelet count - Heparin therapy does not typically affect platelet count, so an increase in platelet count would not indicate a positive response to Heparin therapy. C: decreased fibrin split products - Decreased fibrin split products may not necessarily indicate a positive response to Heparin therapy, as other factors can also influence their levels. D: decreased bleeding - While decreased bleeding can be a positive outcome of Heparin therapy, it is not a direct assessment finding that indicates a positive response to the therapy.
Question 7 of 9
Which nursing activities help promote health and prevent disease?
Correct Answer: A
Rationale: The correct answer is A because reinforcing good habits, such as healthy eating and exercise, is essential for promoting health and preventing disease. This involves educating patients on proper self-care practices. Providing medical diagnosis (B) is not a nursing role, as it falls under the domain of medical professionals. Maintaining optimal functioning (C) is important but not specific to promoting health. Prescribing treatment (D) is beyond the scope of nursing practice, as only advanced practice nurses have prescriptive authority.
Question 8 of 9
A 45-year-old man arrives at the clinic and tells the nurse that he has been experiencing severe chest pain. Upon assessment, the nurse notes that his pain radiates to his left arm. The nurse's priority action would be:
Correct Answer: B
Rationale: The correct answer is B: Assess vital signs and oxygen saturation levels. This is the priority action because the patient's symptoms suggest a possible cardiac event. Assessing vital signs and oxygen saturation levels can provide crucial information on the patient's condition and help determine the urgency of the situation. Administering pain medication (choice A) should not be done before assessing the patient's vital signs. Having the patient walk around (choice C) could worsen the situation if it is indeed a cardiac event. Ordering an EKG (choice D) is important but should come after assessing vital signs to guide further evaluation and treatment.
Question 9 of 9
Which action is most important for a nurse caring for a client with a suspected spinal cord injury?
Correct Answer: A
Rationale: The correct answer is A: Immobilize the client. This is crucial to prevent further damage to the spinal cord. Moving a client with a suspected spinal cord injury can worsen the injury and lead to permanent damage. Immobilizing the client helps maintain spinal alignment and reduces the risk of paralysis. Providing pain relief (B) and loosening clothing (D) are important but secondary actions. Applying pressure to the chest (C) is not recommended for a suspected spinal cord injury as it can also exacerbate the injury.