ATI RN
health assessment test bank Questions
Question 1 of 9
What should a nurse assess for in a client with an arteriovenous fistula for hemodialysis?
Correct Answer: A
Rationale: The correct answer is A: Inspect for visible pulsation. This is because an arteriovenous fistula for hemodialysis should have a visible pulsation, indicating proper blood flow. Palpating for thrill (B) and auscultating for bruit (C) are also common assessments for an arteriovenous fistula, but inspecting for visible pulsation is the most direct and reliable way to assess the patency of the fistula. Percussing for dullness (D) is not relevant in this context as it does not provide information about the vascular access site.
Question 2 of 9
A nurse is assessing a patient who is experiencing dizziness and weakness. The nurse should prioritize which of the following?
Correct Answer: A
Rationale: The correct answer is A: Blood pressure measurement. Dizziness and weakness can be symptoms of hypotension or low blood pressure. Prioritizing blood pressure measurement is crucial because it can indicate if the patient is at risk of complications like cardiovascular collapse. Pulse oximetry (B) is important for assessing oxygen levels in the blood but may not directly address dizziness and weakness. Blood glucose levels (C) are important but not the priority in this scenario. Cardiac monitoring (D) may be necessary but should come after assessing blood pressure to rule out immediate life-threatening conditions.
Question 3 of 9
What should be the nurse's first action for a client with a suspected myocardial infarction (MI)?
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. This is the nurse's first action for a client with a suspected MI because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can help reduce chest pain and prevent further damage to the heart muscle. Administering nitroglycerin promptly is crucial in managing an MI. Monitoring cardiac rhythm (B) and assessing the ECG (C) are important steps, but administering nitroglycerin takes precedence in addressing the client's immediate symptoms. Assisting with positioning (D) is not as urgent or directly related to managing an MI compared to administering nitroglycerin.
Question 4 of 9
Which medication should be administered first for a client with acute asthma exacerbation?
Correct Answer: A
Rationale: Step-by-step rationale for choosing Albuterol as the correct answer: 1. Albuterol is a rapid-acting bronchodilator that provides immediate relief by relaxing the airway muscles during asthma exacerbation. 2. It is the first-line medication recommended by guidelines for acute asthma attacks due to its quick onset of action. 3. Albuterol helps in opening the airways, improving airflow, and relieving symptoms like shortness of breath and wheezing. 4. Epinephrine is not the first choice for asthma exacerbation as it can have more systemic side effects. 5. Levalbuterol is a similar medication to Albuterol but may not be as widely available or cost-effective. 6. IV corticosteroids are important for long-term control but take longer to show effects, making them less suitable as the initial treatment for acute exacerbation.
Question 5 of 9
A nurse is caring for a patient with chronic kidney disease (CKD). Which of the following lab results would the nurse expect to be elevated in this patient?
Correct Answer: A
Rationale: The correct answer is A: Blood urea nitrogen (BUN). In CKD, the kidneys are unable to effectively filter waste products, leading to an increase in BUN levels. Elevated BUN indicates impaired kidney function. Calcium, potassium, and sodium levels may also be affected in CKD, but they are more likely to be imbalanced rather than consistently elevated. Calcium levels may be low due to impaired vitamin D activation, potassium levels may be high due to decreased excretion, and sodium levels can fluctuate based on fluid status. Therefore, while these lab values may be abnormal in CKD, BUN is the most consistently elevated marker of kidney dysfunction.
Question 6 of 9
Which technique should the nurse use to determine the presence of crepitus during a physical examination?
Correct Answer: A
Rationale: The correct technique to determine the presence of crepitus during a physical examination is palpation. Crepitus is a crackling or grating sensation that is felt when there is air trapped in the subcutaneous tissue. Palpation involves using the hands to feel for abnormalities such as crepitus. Percussion involves tapping on the body to produce sounds that can help assess underlying structures, not to determine the presence of crepitus. Auscultation is listening to sounds within the body using a stethoscope, which is not relevant for detecting crepitus.
Question 7 of 9
A nurse is teaching a patient with asthma about managing asthma attacks. Which of the following statements by the patient indicates proper understanding?
Correct Answer: A
Rationale: Correct Answer: A Rationale: Using the inhaler when feeling an asthma attack coming on allows for prompt relief by opening airways. Waiting for symptoms to worsen (B) can lead to a severe attack. Using the inhaler only when short of breath (C) may delay treatment. Skipping the inhaler when feeling fine (D) can be dangerous if an attack occurs suddenly. Answer A ensures timely intervention for effective asthma management.
Question 8 of 9
What is the most appropriate intervention for a client with severe nausea and vomiting?
Correct Answer: A
Rationale: The correct answer is A: Administer antiemetics. Antiemetics help alleviate nausea and vomiting by blocking neurotransmitters in the brain. This intervention directly targets the symptoms and provides relief for the client. Administering fluids (B) may help with hydration but does not address the root cause. Administering analgesics (C) is for pain relief, not for nausea and vomiting. Monitoring electrolytes (D) is important but does not directly treat the symptoms. Therefore, administering antiemetics is the most appropriate intervention for severe nausea and vomiting.
Question 9 of 9
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Administering bronchodilators as prescribed. Rationale: 1. Bronchodilators help dilate the airways, improving airflow in COPD patients. 2. Priority is to address the underlying respiratory issue. 3. Bronchodilators are a standard treatment for managing COPD symptoms. 4. Improving airway patency is crucial in COPD exacerbations. Summary: - B: Encouraging avoidance of physical activity is incorrect as it can lead to deconditioning. - C: Providing supplemental oxygen is important but not the priority in this case. - D: Monitoring for acute kidney injury is unrelated to COPD management.