Questions 9

ATI RN

ATI RN Test Bank

hesi health assessment test bank Questions

Question 1 of 5

Which intervention should the nurse implement for a client with hypothermia?

Correct Answer: B

Rationale: The correct answer is B, removing the client from the cold environment. This is because hypothermia occurs when the body loses heat faster than it can produce it, and being in a cold environment exacerbates this process. By removing the client from the cold environment, the nurse helps stop further heat loss. Warming the client slowly (A) can be detrimental as rapid rewarming can lead to complications. Providing a warm environment (C) and applying warm blankets (D) are important interventions but should come after removing the client from the cold environment to prevent further heat loss.

Question 2 of 5

What should the nurse do first when a client presents with severe chest pain?

Correct Answer: D

Rationale: The correct answer is D: Encourage deep breathing. This is because encouraging deep breathing can help alleviate anxiety and promote relaxation, which can be beneficial in managing severe chest pain. Administering nitroglycerin (A) should only be done after assessing the client's condition and confirming it is safe to do so. Providing pain relief (B) may be necessary, but addressing the root cause of the pain should be the priority. Monitoring ECG (C) is important but should come after ensuring the client's immediate needs are addressed.

Question 3 of 5

Which condition places a client at risk for a high ammonia level?

Correct Answer: D

Rationale: The correct answer is D: cirrhosis. Cirrhosis leads to impaired liver function, causing the liver to be unable to effectively metabolize ammonia, leading to high ammonia levels in the blood. Renal failure (choice A) is associated with high creatinine levels, not ammonia. Psoriasis (choice B) is a skin condition unrelated to ammonia levels. Lupus (choice C) is an autoimmune disease affecting various organs, not directly linked to high ammonia levels. In summary, cirrhosis is the only condition among the options that directly impacts liver function and can lead to high ammonia levels in the blood.

Question 4 of 5

What should the nurse do when a client develops a deep vein thrombosis (DVT)?

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants help prevent the blood clot from getting larger and reduce the risk of it breaking loose and causing a pulmonary embolism. Other choices are incorrect because B: Monitoring vital signs alone does not treat the DVT, C: Providing bed rest can increase the risk of complications like pulmonary embolism, and D: Administering fibrinolytics is not the first-line treatment for DVT.

Question 5 of 5

What is the first nursing action for a client who develops a seizure?

Correct Answer: A

Rationale: The correct answer is A: Place the client on their side. This is the first nursing action for a client who develops a seizure to prevent aspiration and maintain an open airway. Placing the client on their side helps to keep their airway clear and prevents them from choking on saliva or vomit. Choice B, loosening clothing, is important but not the first priority. Choice C, placing the client in a Trendelenburg position, is not recommended as it may increase intracranial pressure. Choice D, placing the client in a sitting position, can increase the risk of injury during a seizure.

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