ATI RN
test bank for health assessment Questions
Question 1 of 5
What should the nurse do if a client experiences an allergic reaction to a medication?
Correct Answer: D
Rationale: The correct answer is D because when a client experiences an allergic reaction to a medication, the nurse should monitor for signs of infection as allergic reactions can sometimes lead to secondary infections. By closely monitoring the client for signs of infection, the nurse can promptly intervene and provide appropriate treatment. A: Discontinuing the medication is important but not the immediate priority when dealing with an allergic reaction. B: Notifying the healthcare provider is important, but monitoring for signs of infection takes precedence in this situation. C: Administering antihistamines may help with allergic symptoms but does not address the potential risk of secondary infection.
Question 2 of 5
What is the most important priority for a nurse caring for a client with pneumonia?
Correct Answer: D
Rationale: The correct answer is D: Administer diuretics. The priority for a nurse caring for a client with pneumonia is to maintain adequate oxygenation and prevent respiratory failure. Diuretics help reduce fluid overload in the lungs, improving gas exchange and oxygenation. Administering antibiotics (choice A) is important to treat the infection but not the top priority. Administering oxygen (choice B) is crucial for oxygenation, but diuretics take precedence to improve lung function. Administering corticosteroids (choice C) may be considered in certain cases to reduce inflammation, but it is not the primary priority.
Question 3 of 5
What is the priority nursing action for a client who is receiving blood transfusion and develops a fever?
Correct Answer: A
Rationale: Step 1: Stop the transfusion - Febrile reaction can indicate a transfusion reaction, so stopping the transfusion is crucial. Step 2: Administer antipyretics - To reduce fever and prevent further complications. Step 3: Assess for other signs of transfusion reaction - Such as chills, rash, or hypotension. Summary: Option A is correct as it addresses the immediate need to stop the transfusion and manage the fever. Options B, C, and D do not prioritize stopping the transfusion, which is crucial in this scenario.
Question 4 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 5 of 5
What is the most important nursing action for a client who has a history of seizures?
Correct Answer: A
Rationale: The correct answer is A: Administer antiepileptic drugs. This is the most important nursing action for a client with a history of seizures because antiepileptic drugs help prevent or reduce the frequency and severity of seizures. By ensuring the client receives their prescribed medication, the nurse can help manage the condition effectively. Placing the client on their side (B) is important to prevent aspiration if a seizure occurs, but administering antiepileptic drugs is more crucial for long-term management. Checking the airway (C) is important during and after a seizure but does not address the underlying cause. Monitoring for hypoglycemia (D) is important as a potential trigger for seizures, but administering antiepileptic drugs takes precedence in managing the condition.