ATI RN
health assessment test bank Questions
Question 1 of 5
Which intervention should be performed when assessing a client with an arteriovenous fistula (AVF) for hemodialysis?
Correct Answer: C
Rationale: Correct Answer: C - Administer IV fluids Rationale: 1. Assess patient's fluid status and hydration level. 2. IV fluids help maintain adequate hydration during hemodialysis. 3. Prevents hypotension and ensures stable blood pressure during the procedure. 4. Improves overall hemodialysis efficiency and patient safety. Summary: A: Checking patency is important, but not the primary intervention for hemodialysis. B: Monitoring for bleeding is crucial but not specific to AVF assessment. D: Applying an airtight dressing is not necessary for AVF assessment.
Question 2 of 5
What is the priority nursing intervention for a client with a history of asthma experiencing wheezing?
Correct Answer: A
Rationale: The priority nursing intervention for a client with asthma experiencing wheezing is to administer oxygen. Wheezing indicates airway constriction and decreased oxygenation, making oxygen crucial for adequate tissue perfusion. Administering oxygen helps improve oxygen levels, alleviate respiratory distress, and prevent hypoxemia. Applying a bronchodilator (Choice B) may be beneficial after oxygen is administered. Applying a cold compress (Choice C) is not indicated for asthma exacerbations, and encouraging deep breathing (Choice D) may worsen respiratory distress in a client with wheezing. In summary, administering oxygen is the priority intervention to address the immediate respiratory needs of the client with asthma and wheezing.
Question 3 of 5
What is the first step in the care of a client with a severe allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. This is the first step in the care of a client with a severe allergic reaction because epinephrine is the primary medication used to reverse the life-threatening symptoms of anaphylaxis. Epinephrine acts quickly to constrict blood vessels, relax smooth muscles in the lungs to improve breathing, and increase heart rate. Administering epinephrine promptly can prevent progression to severe outcomes like respiratory failure or shock. Corticosteroids (B and C) are used as adjunct therapy and do not provide immediate relief. Applying a cold compress (D) does not address the systemic effects of anaphylaxis and can delay potentially life-saving treatment.
Question 4 of 5
What is the priority nursing action for a client with a suspected stroke?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygenation is the priority in stroke management to ensure adequate oxygen supply to the brain. Oxygen therapy can help reduce hypoxia, which is crucial in the acute phase of a stroke. Administering aspirin (B) is important but comes after ensuring oxygenation. Administering thrombolytics (C) requires proper assessment and diagnostic confirmation, not an immediate priority. Placing the client in a supine position (D) may worsen stroke symptoms if there is compromised blood flow, so it is not recommended as the initial action.
Question 5 of 5
What is the most effective action for a client with suspected sepsis?
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating sepsis as they help to fight the underlying infection causing the condition. Administering antibiotics promptly can prevent the infection from spreading and worsening. Fluids (choices B and C) are important for treating sepsis to maintain blood pressure and support organ function, but antibiotics are the primary intervention to target the infection. Administering oxygen (choice D) may be necessary to support respiratory function in septic patients, but it is not the most effective action to address the underlying infection.