ATI RN
Health Assessment Practice Questions Questions
Question 1 of 9
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 2 of 9
The nurse is obtaining history for a 3-month-old infant. During the interview, the mother states,"I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be:
Correct Answer: A
Rationale: The correct answer is A because drooling is a common sign of teething in infants. The nurse's response should validate the mother's observation to build trust and rapport. Choice B is incorrect because teething can start as early as 3 months. Choice C is incorrect as drooling is a normal developmental milestone in infants. Choice D is incorrect as infants do not consciously control saliva production.
Question 3 of 9
A nurse is caring for a 70-year-old patient with a history of congestive heart failure. The nurse should monitor the patient for which of the following?
Correct Answer: A
Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.
Question 4 of 9
The nurse is conducting an eye clinic at the day care centre. When examining a 2-year-old child, if"lazy eye" is suspected, the nurse would:
Correct Answer: D
Rationale: The correct answer is D because testing for strabismus by performing the corneal light reflex test is crucial in diagnosing "lazy eye" or amblyopia in children. Strabismus is a condition where the eyes are misaligned, leading to poor vision in one eye. By performing the corneal light reflex test, the nurse can assess if the child's eyes are aligned or if there is deviation, which could indicate lazy eye. Options A, B, and C are incorrect as they do not specifically address the assessment of strabismus, which is the key indicator for lazy eye in this scenario.
Question 5 of 9
In a patient with anisocoria, the nurse would expect to observe:
Correct Answer: C
Rationale: Step-by-step rationale: 1. Anisocoria is a condition where pupils are of unequal size. 2. It is typically caused by issues in the eye muscles or nerves controlling pupil size. 3. The nurse would expect to observe pupils of different sizes. 4. Dilated pupils (choice A) and excessive tearing (choice B) are not indicative of anisocoria. 5. An uneven curvature of the lens (choice D) does not directly relate to pupil size differences. Summary: Correct answer C is supported by the definition of anisocoria and its usual presentation. Choices A, B, and D are incorrect as they do not align with the characteristic feature of anisocoria.
Question 6 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 7 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 8 of 9
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. This is the priority intervention as it helps prevent complications such as blood clots and pneumonia, promotes circulation, and aids in faster recovery. Ambulation also helps maintain joint mobility and muscle strength. Administering pain medications (B) is important but not the priority. Providing wound care (C) and monitoring for infection (D) are important, but ambulation takes precedence in preventing complications.
Question 9 of 9
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.