ATI RN
Health Assessment Practice Questions Questions
Question 1 of 9
Which value should a nurse monitor closely when a client is on TPN?
Correct Answer: C
Rationale: The correct answer is C: Glucose. Total Parenteral Nutrition (TPN) is a form of nutrition delivered directly into the bloodstream, providing all essential nutrients including glucose. Monitoring glucose levels is crucial to prevent hyperglycemia or hypoglycemia. Calcium (A), Magnesium (B), and Cholesterol (D) are not typically monitored closely when a client is on TPN, as they are not directly impacted by TPN administration. Calcium and Magnesium levels are usually monitored for other conditions, and Cholesterol levels are not typically affected by TPN administration.
Question 2 of 9
What is the most appropriate intervention for a client with a severe burn?
Correct Answer: D
Rationale: The correct answer is D: Cover the burn site with a clean, dry dressing. This intervention helps protect the burn from infection, promotes healing, and reduces pain. Ice can further damage the skin. Pain medication may be needed but does not address wound care. Maintaining a sterile dressing is crucial, but covering with a clean, dry dressing is more practical and achievable in most settings.
Question 3 of 9
A nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about self-management. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C because using the inhaler every time the patient feels short of breath, even without a flare-up, is not the recommended practice for managing COPD. Inhalers should be used as prescribed by the healthcare provider or only during exacerbations. Here's the rationale: 1. Using the inhaler excessively can lead to overuse of medication and potential side effects. 2. It is important for patients to differentiate between regular management and acute exacerbations. 3. Monitoring oxygen levels (choice D) is essential for COPD management. 4. Quitting smoking (choice A) and deep breathing exercises (choice B) are positive self-management strategies for COPD.
Question 4 of 9
When performing an otoscopic examination on a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in colour and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information would be that:
Correct Answer: A
Rationale: The correct answer is A: this is most likely serous otitis media. In a child with chronic ear infections, amber-yellow tympanic membrane color and air bubbles suggest fluid accumulation behind the eardrum, characteristic of serous otitis media. The occasional hearing loss and popping sound with swallowing are also common symptoms. Serous otitis media is a non-infectious condition caused by Eustachian tube dysfunction. Choice B: Acute purulent otitis media presents with more severe symptoms like fever and severe ear pain, which are not mentioned in the case. Choice C: Cholesteatoma is a more serious condition characterized by a cyst-like growth in the middle ear, not just fluid accumulation as seen in this case. Choice D: Perforation typically presents with a visible hole in the eardrum and is not consistent with the findings of fluid and air bubbles in this case.
Question 5 of 9
Which value should a nurse monitor closely when a client is on TPN?
Correct Answer: C
Rationale: The correct answer is C: Glucose. Total Parenteral Nutrition (TPN) is a form of nutrition delivered directly into the bloodstream, providing all essential nutrients including glucose. Monitoring glucose levels is crucial to prevent hyperglycemia or hypoglycemia. Calcium (A), Magnesium (B), and Cholesterol (D) are not typically monitored closely when a client is on TPN, as they are not directly impacted by TPN administration. Calcium and Magnesium levels are usually monitored for other conditions, and Cholesterol levels are not typically affected by TPN administration.
Question 6 of 9
A 92-year-old patient has had a stroke, and the right side of his face is drooping. What else would the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. In a stroke patient with right-sided facial drooping, dysphagia is highly likely due to the involvement of the facial nerve, leading to difficulty swallowing. Epistaxis (A) is nosebleeds, agenesis (B) is the absence of a body part, and xerostomia (D) is dry mouth, which are not directly related to facial drooping in stroke patients. Dysphagia is a common complication post-stroke due to impaired muscle control, making it the most likely concern for the nurse to suspect in this case.
Question 7 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 8 of 9
In using the ophthalmoscope to assess a patient's eyes, the nurse notes a red glow in the patient's pupils. On the basis of this finding, the nurse would:
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. Red glow in pupils indicates a normal reflection off the inner retina known as the red reflex. 2. The red reflex helps to visualize the internal structures of the eye, including the retina. 3. This finding is expected during an ophthalmoscopic examination. 4. No abnormality is suggested by the presence of a red glow in the pupils. Summary of Other Choices: A: Incorrect. Red glow does not indicate an opacity in the lens or cornea. B: Incorrect. Checking the light source is unnecessary as red glow is a normal finding. D: Incorrect. Referral is not needed as red reflex is a normal part of an ophthalmoscopic exam.
Question 9 of 9
What is the most appropriate action for a nurse when caring for a client with severe hypothermia?
Correct Answer: A
Rationale: The correct answer is A: Administer warm IV fluids. This is because in severe hypothermia, the body's core temperature drops dangerously low, leading to decreased circulation and potential organ failure. Administering warm IV fluids helps to gradually raise the core temperature and prevent further complications. Choice B (Warming the client with a heating pad) can cause rewarming shock and skin burns. Choice C (Placing the client in a supine position) is not directly related to treating hypothermia. Choice D (Administering analgesics) is not the priority in treating severe hypothermia.