ATI RN
Health Assessment Practice Questions Questions
Question 1 of 5
What should the nurse do when a client develops severe shortness of breath after surgery?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. This is the priority intervention to address severe shortness of breath, ensuring the client receives adequate oxygenation. Administering oxygen helps improve oxygen saturation levels and supports respiratory function. Encouraging deep breathing (B) may exacerbate the client's distress. Elevating the head of the bed (C) can help improve breathing but does not address the immediate need for oxygen. Administering antibiotics (D) is not indicated for shortness of breath unless there is an underlying infection causing it.
Question 2 of 5
What should be the nurse's first action when a client develops a fever after surgery?
Correct Answer: A
Rationale: The correct first action when a client develops a fever after surgery is to administer antipyretics (A). Fever post-surgery can indicate infection, and antipyretics help lower the body temperature. Administering pain medications (B) may mask the fever's underlying cause. Providing fluids (C) is essential but not the priority. Providing wound care (D) is important but comes after addressing the fever. Administering antipyretics promptly helps manage the fever and allows for further assessment and intervention if needed.
Question 3 of 5
What is the most appropriate nursing intervention for a client with severe pain after surgery?
Correct Answer: A
Rationale: The correct answer is A: Administer pain medication. This is the most appropriate nursing intervention because severe pain post-surgery requires immediate relief to ensure the client's comfort and aid in recovery. Pain medication helps manage pain effectively, improving the client's overall well-being and promoting healing. Monitoring vital signs (choice B) is important but secondary to pain relief in this scenario. Administering IV fluids (choice C) may be necessary for hydration but does not directly address the pain. Administering corticosteroids (choice D) is not typically indicated for severe pain post-surgery.
Question 4 of 5
What should the nurse do when a client is experiencing hyperglycemia?
Correct Answer: A
Rationale: The correct answer is A, administer insulin, because hyperglycemia indicates high blood sugar levels which can be effectively lowered by administering insulin. Insulin helps to move glucose from the blood into cells for energy production. Administering fluids (B) can be helpful for dehydration, but it does not directly address the high blood sugar levels. Encouraging activity (C) may help lower blood sugar levels over time, but in the immediate situation, administering insulin is more effective. Encouraging deep breathing (D) does not directly address hyperglycemia and would not be the appropriate first step in managing this condition.
Question 5 of 5
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.