ATI RN
health assessment test bank jarvis Questions
Question 1 of 5
Which of the following is the most appropriate response for a nurse caring for a client who is experiencing a stroke?
Correct Answer: B
Rationale: The correct answer is B: Initiate a stroke protocol. This is the most appropriate response because time is critical in treating a stroke. By initiating a stroke protocol, the nurse ensures that the client receives prompt and appropriate care, including timely evaluation, imaging studies, and potential interventions such as administering clot-busting medication. Performing a neurological assessment (A) is important but may delay crucial interventions. Positioning the client on their side (C) is essential for airway protection but should not be the initial priority. Starting a CT scan (D) is important for diagnosis but should not delay the initiation of the stroke protocol, which includes obtaining imaging studies.
Question 2 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 3 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 4 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.
Question 5 of 5
What is the first action the nurse should take when a client develops a deep vein thrombosis (DVT)?
Correct Answer: A
Rationale: The correct answer is A: Elevate the affected leg. This is the first action because elevating the leg helps reduce swelling and improve blood flow, reducing the risk of complications from the DVT. It also helps alleviate pain. Choice B: Applying compression stockings can be helpful in preventing DVT, but it is not the first action to take once it has developed. Choice C: Providing leg elevation is similar to choice A, but it lacks the specificity of elevating the affected leg to address the DVT directly. Choice D: Administering compression therapy may be necessary, but it is not the initial action to take when a client develops a DVT.