ATI RN
health assessment test bank jarvis Questions
Question 1 of 5
Which lab result is most indicative of infection in a client with a fever?
Correct Answer: A
Rationale: The correct answer is A: Increased white blood cell count. When a client has an infection, the body's immune response triggers an increase in white blood cells to help fight off the infection. Neutrophils and band cells (choice B) may also increase during infection, but a general increase in white blood cells is a more reliable indicator. ESR (choice C) is a nonspecific marker of inflammation and may be elevated in various conditions, not just infection. LDH (choice D) is an enzyme found in many tissues and can be elevated in various conditions, not specifically infection. Therefore, an increased white blood cell count is the most indicative of infection in a client with a fever.
Question 2 of 5
What is the primary concern for a nurse caring for a client who is post-operative and experiencing confusion?
Correct Answer: B
Rationale: The correct answer is B: Reorient the client. Reorientation helps the confused client regain awareness of their surroundings, time, and situation post-operatively. It can improve their cognition and reduce anxiety. Notifying the healthcare provider (A) may be necessary but not the primary concern. Increasing circulation (C) is important but not the first step for a confused post-op client. Assessing pain (D) is important but addressing confusion takes precedence.
Question 3 of 5
Which of the following actions is the nurse's priority when caring for a client with a suspected stroke?
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's ECG. This is the priority because it helps in detecting any cardiac abnormalities or arrhythmias which are common in stroke patients. Assessing neurologic status (A) is important but monitoring the ECG takes precedence. Starting an IV line and administering thrombolytics (B) should be done as per protocol but is not the immediate priority. Providing emotional support (D) is important, but ensuring the client's cardiac status is stable is crucial in the acute phase of stroke.
Question 4 of 5
Which of the following actions is the nurse's priority when caring for a client with a head injury?
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's airway. This is the priority because airway management is crucial in ensuring adequate oxygenation and ventilation, which is essential for brain function in a client with a head injury. Maintaining a clear airway takes precedence over other actions such as administering pain relief, performing a CT scan, or monitoring intracranial pressure. While these actions are important, ensuring the client's airway is patent and adequate oxygenation is crucial for preventing further brain injury or complications.
Question 5 of 5
What is the most important nursing intervention for a client with pneumonia?
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating pneumonia caused by bacteria. They help to kill the bacteria causing the infection and prevent its spread. Administering fluids (B) is important for hydration but not the most crucial intervention. Monitoring temperature (C) is important but does not treat the root cause. Administering vaccines (D) may prevent certain types of pneumonia but is not the immediate intervention for an existing infection. Administering antibiotics promptly is vital to effectively treat pneumonia and prevent complications.