Questions 9

ATI RN

ATI RN Test Bank

test bank for health assessment Questions

Question 1 of 5

What should the nurse do first for a client who is post-operative and experiencing confusion?

Correct Answer: B

Rationale: The correct answer is B: Place in a safe environment. This is the first priority to ensure the safety of the confused post-operative client. Placing the client in a safe environment prevents harm from falls or accidents. Reorienting the client (choice A) can come after ensuring safety. Administering pain relief (choices C and D) should be done based on assessment but is not the first priority when the client is confused.

Question 2 of 5

What should the nurse do when caring for a client who is experiencing an anaphylactic reaction?

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it helps to quickly reverse severe symptoms by constricting blood vessels and opening airways. Administering corticosteroids (B) is not the immediate priority. Placing the client on their side (C) is important to prevent aspiration but does not address the anaphylactic reaction. Monitoring blood pressure (D) is essential but administering epinephrine takes precedence in managing anaphylaxis.

Question 3 of 5

What is the most important action when caring for a client on intravenous heparin?

Correct Answer: A

Rationale: The correct answer is A: Monitor aPTT levels. This is crucial in intravenous heparin therapy to ensure the therapeutic range is maintained for anticoagulation without causing bleeding. Monitoring aPTT helps adjust heparin dosage to prevent clot formation or excessive bleeding. B: Monitoring for bleeding is important but not the most important action compared to monitoring aPTT levels for appropriate dosing. C: Checking platelet count is important for some anticoagulants like heparin, but aPTT monitoring is more directly related to heparin's anticoagulant effect. D: Administering a heparin antidote (protamine sulfate) is necessary in case of heparin overdose or in emergency situations but is not the primary action in routine care.

Question 4 of 5

Which sign might a nurse observe in a client with a high ammonia level?

Correct Answer: A

Rationale: The correct answer is A: coma. High ammonia levels can lead to hepatic encephalopathy, causing impaired brain function and potentially leading to coma. Edema (B) is typically associated with fluid retention, not high ammonia levels. Hypoxia (C) is a condition of low oxygen levels, not directly related to high ammonia levels. Polyuria (D) is excessive urination, which is not a common sign of high ammonia levels.

Question 5 of 5

What do nursing activities that promote health and prevent disease accomplish? (Select one that doesn't apply)

Correct Answer: D

Rationale: The correct answer is D: Create home care safety. Nursing activities that promote health and prevent disease focus on educating individuals on maintaining their health and preventing diseases, rather than specifically creating home care safety. The other choices (A, B, C) are correct as they accurately reflect the goals of nursing activities - reducing disease risk, maintaining optimal functioning, and reinforcing good habits to promote overall health and well-being. Choice D is incorrect because while ensuring home care safety is important, it is not the primary focus of nursing activities aimed at health promotion and disease prevention.

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