ATI RN
hesi health assessment test bank 2023 Questions
Question 1 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.
Question 2 of 5
A nurse is caring for a patient who is post-operative following abdominal surgery. Which of the following signs and symptoms would the nurse consider as an early indicator of infection?
Correct Answer: A
Rationale: The correct answer is A: Fever. Fever is an early indicator of infection as it is the body's natural response to fighting off pathogens. When the body detects an infection, it raises its temperature to create an inhospitable environment for the pathogens. Pain at the surgical site (B) is common post-operatively but may not necessarily indicate infection. Redness at the incision site (C) can be a sign of inflammation but is not specific to infection. Increased heart rate (D) can occur due to various reasons post-operatively, not just infection. Fever is a systemic response and a more reliable early indicator of infection in this context.
Question 3 of 5
What is the most appropriate action when a client presents with acute abdominal pain?
Correct Answer: C
Rationale: The correct answer is C: Monitor blood pressure. When a client presents with acute abdominal pain, monitoring blood pressure is crucial as it can help assess for potential complications like hypovolemic shock or internal bleeding. Changes in blood pressure may indicate worsening condition and prompt the need for immediate intervention. Monitoring vital signs (A) is important but blood pressure takes precedence in this scenario. Assessing abdominal tenderness (B) is valuable but does not directly address potential life-threatening issues. Monitoring for dehydration (D) is also important but not the most immediate concern in the case of acute abdominal pain.
Question 4 of 5
A nurse is caring for a patient with pneumonia. Which of the following interventions should the nurse prioritize?
Correct Answer: B
Rationale: The correct answer is B: Administering oxygen as prescribed. Oxygen therapy is a critical intervention in pneumonia to improve oxygenation and prevent hypoxia. Priority is given to interventions that address the immediate physiological needs of the patient. Encouraging fluid intake (A) is important but not as urgent as oxygen therapy. Encouraging ambulation (C) can be beneficial for overall health but may not be suitable for a patient with pneumonia. Providing pain medication (D) is important for comfort but is not the priority in this case.
Question 5 of 5
A nurse is assessing a patient with a history of stroke. The nurse should monitor for signs of which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.