ATI RN
hesi health assessment test bank 2023 Questions
Question 1 of 9
Which medication should be used to treat anaphylaxis?
Correct Answer: A
Rationale: The correct answer is A: Epinephrine. It is the first-line treatment for anaphylaxis as it rapidly reverses severe allergic reactions by constricting blood vessels, relaxing airway muscles, and increasing heart rate. Diphenhydramine (B) and steroids (C) are used as adjunct therapies but do not provide immediate relief like epinephrine. Albuterol (D) is used for bronchospasm in asthma, not for anaphylaxis. In summary, epinephrine is the most effective and life-saving medication for treating anaphylaxis.
Question 2 of 9
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should monitor for which of the following complications?
Correct Answer: D
Rationale: The correct answer is D: Atelectasis and pneumonia. Following abdominal surgery, patients are at risk for atelectasis (lung collapse) due to shallow breathing and pneumonia due to impaired lung function. A nurse should monitor for signs such as decreased oxygen saturation, increased respiratory rate, and crackles on auscultation. Wound infection (A) is a common post-operative complication but not specific to abdominal surgery. Hyperglycemia (B) may occur due to stress response but is not directly related to abdominal surgery. Dehydration (C) is a concern post-operatively, but respiratory complications like atelectasis and pneumonia are higher priority due to potential life-threatening consequences.
Question 3 of 9
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. This is the priority intervention as it helps prevent complications such as blood clots and pneumonia, promotes circulation, and aids in faster recovery. Ambulation also helps maintain joint mobility and muscle strength. Administering pain medications (B) is important but not the priority. Providing wound care (C) and monitoring for infection (D) are important, but ambulation takes precedence in preventing complications.
Question 4 of 9
A nurse is caring for a patient who has been prescribed warfarin. The nurse should monitor the patient for signs of which of the following?
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Warfarin is an anticoagulant medication that works by inhibiting blood clotting factors. Monitoring for signs of bleeding is crucial as warfarin increases the risk of bleeding events. Signs of bleeding may include easy bruising, nosebleeds, blood in urine or stool. Hypertension (B), hyperglycemia (C), and hypokalemia (D) are not direct effects of warfarin. Monitoring for these conditions may be important for other medications or conditions, but they are not the primary concern when a patient is prescribed warfarin.
Question 5 of 9
Which medication should be given to treat anemia in clients with renal failure?
Correct Answer: A
Rationale: Correct Answer: A (Iron, folic acid, and B12) Rationale: 1. Iron: Renal failure patients often have anemia due to decreased erythropoietin production. 2. Folic acid and B12: Important for red blood cell production and maturation. 3. Corrects underlying causes of anemia in renal failure patients. Summary: B: Increasing protein doesn't directly address anemia in renal failure. C: Vitamin D and calcium are not primary treatments for anemia in renal failure. D: Calcium and folic acid alone do not address the specific deficiencies seen in renal failure anemia.
Question 6 of 9
A nurse is teaching a patient with a history of stroke about reducing the risk of another stroke. Which of the following lifestyle changes should the nurse emphasize?
Correct Answer: D
Rationale: The correct answer is D: All of the above. This is the best choice because reducing the risk of another stroke requires a holistic approach. A: Limiting sodium and cholesterol intake helps manage blood pressure and cholesterol levels, reducing the risk of stroke. B: Increasing physical activity and managing weight can improve cardiovascular health and overall well-being, reducing the risk of stroke. C: Taking prescribed medications regularly, such as blood thinners or antihypertensives, is crucial in preventing another stroke. In summary, all three choices address key risk factors for stroke prevention, making them essential components of a comprehensive stroke prevention plan.
Question 7 of 9
What should the nurse do first for a client with a history of diabetes who is experiencing hypoglycemia?
Correct Answer: A
Rationale: The correct answer is A: Administer glucose. In hypoglycemia, the priority is to raise the low blood sugar levels quickly. Administering glucose is the most direct and effective way to do so. Glucose will rapidly increase the blood sugar levels and help the client recover from hypoglycemia. Administering insulin (B) would further lower blood sugar levels. Administering glucagon (C) is used for severe hypoglycemia when the client is unconscious. Encouraging deep breathing (D) is not effective in treating hypoglycemia and does not address the immediate need to raise blood sugar levels.
Question 8 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 9 of 9
What is the first priority for a client with suspected sepsis?
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. In sepsis, early fluid resuscitation is crucial to prevent hypotension and organ dysfunction. IV fluids help restore perfusion and stabilize the client. Administering antibiotics (choice B) is important but comes after fluid resuscitation. Performing a blood culture (choice C) is essential but not the first priority. Performing an abdominal assessment (choice D) is not directly related to managing sepsis and should not be the initial priority.