ATI RN
hesi health assessment test bank 2023 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
A nurse is assessing a patient with a history of smoking. The patient reports a persistent cough that has worsened over the past few months. The nurse would be most concerned about the possibility of:
Correct Answer: B
Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). The patient's history of smoking, persistent cough, and worsening symptoms over months are indicative of COPD, a progressive lung disease commonly caused by smoking. Asthma (A) typically presents with intermittent symptoms, bronchitis (C) may cause cough but not necessarily worsening over time, and pulmonary embolism (D) is characterized by sudden onset symptoms and is less likely in this case. COPD is the most concerning due to the patient's smoking history and progressive symptoms.
Question 3 of 9
Which food should be avoided by clients prone to heartburn from GERD?
Correct Answer: C
Rationale: The correct answer is C: Chocolate. Chocolate is known to trigger heartburn in individuals with GERD due to its high fat content and caffeine. Fat relaxes the lower esophageal sphincter, allowing stomach acid to flow back up the esophagus, leading to heartburn. Caffeine can also relax the sphincter and trigger acid reflux. Lettuce (A) and eggs (B) are generally well-tolerated and do not commonly trigger heartburn. Butterscotch (D) may be high in fat and sugar, but it is less likely to cause heartburn compared to chocolate.
Question 4 of 9
A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice?
Correct Answer: A
Rationale: The correct answer is A: A trained interpreter. Choosing a trained interpreter ensures accurate communication and confidentiality. Professional interpreters have the necessary language skills and cultural competence to facilitate effective communication between the healthcare provider and the patient. Using a family member (choices B and C) may compromise confidentiality and accuracy due to potential bias or lack of professional training. Similarly, selecting a volunteer university student (choice D) may result in misinterpretation or breach of privacy as they may not have the same level of expertise as a trained interpreter. Ultimately, the most appropriate choice is a trained interpreter to ensure clear and accurate communication while respecting the patient's privacy and dignity.
Question 5 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 6 of 9
A nurse is caring for a patient with chronic kidney disease (CKD). The nurse should monitor for which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In CKD, the kidneys are unable to effectively excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac complications. Hyperkalemia is a common and critical complication in CKD patients. B: Hypokalemia is unlikely in CKD as the kidneys typically retain potassium. C: Hyperglycemia is more commonly associated with diabetes rather than CKD. D: Hypercalcemia is not a common complication of CKD; in fact, CKD often leads to lower calcium levels due to impaired activation of vitamin D.
Question 7 of 9
Which nursing activities help promote health and prevent disease?
Correct Answer: A
Rationale: The correct answer is A because reinforcing good habits, such as healthy eating and exercise, is essential for promoting health and preventing disease. This involves educating patients on proper self-care practices. Providing medical diagnosis (B) is not a nursing role, as it falls under the domain of medical professionals. Maintaining optimal functioning (C) is important but not specific to promoting health. Prescribing treatment (D) is beyond the scope of nursing practice, as only advanced practice nurses have prescriptive authority.
Question 8 of 9
A nurse is teaching a patient with heart failure about managing their condition. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C: "I can stop taking my medication if I feel fine." This statement indicates a misunderstanding of the importance of medication adherence in managing heart failure. Here's the rationale: 1. Patients with heart failure often require lifelong medication to control symptoms and prevent complications. 2. Stopping medication abruptly can lead to worsening of heart failure symptoms and potential health risks. 3. Monitoring for symptoms is essential, but it does not replace the need for consistent medication use. Other choices are incorrect because: A is correct as daily medication adherence is crucial. B is correct as reducing sodium intake helps manage fluid retention in heart failure. D is correct as daily weight monitoring helps detect fluid retention early.
Question 9 of 9
What is the nurse's first priority when caring for a client with severe trauma?
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief. The nurse's first priority is to address pain and ensure the client's comfort and well-being. Pain relief helps reduce distress, improve communication, and prevent complications. Monitoring blood pressure (B) and providing hydration (C) are important but not the immediate priority in severe trauma. Administering a blood transfusion (D) may be necessary but is not the first priority compared to addressing pain and stabilizing the client.