ATI RN
health assessment exam 1 test bank Questions
Question 1 of 5
While auscultating for heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next?
Correct Answer: A
Rationale: The correct answer is A because documenting the findings is essential for accurate patient care and communication among healthcare professionals. By documenting the unfamiliar sound heard during auscultation, the nurse ensures that the information is recorded for future reference and potential follow-up assessments or interventions. Waiting 10 minutes (B) may not address the immediate need for documentation. Asking another nurse to double-check (C) may be helpful but does not address the importance of documenting the finding. Asking the patient to take deep breaths (D) is not the appropriate next step when an unfamiliar heart sound is detected; documentation is crucial before further assessment or intervention.
Question 2 of 5
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for signs of which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD are at risk for respiratory failure due to impaired gas exchange and respiratory muscle weakness. This can lead to hypoxia and hypercapnia. Monitoring for signs such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial. Hypoglycemia (A) is not a common complication of COPD. Hyperkalemia (C) is less likely to occur in COPD unless the patient is on medications that can cause elevated potassium levels. Anemia (D) may be present in COPD due to chronic inflammation, but it is not a direct complication that requires monitoring for signs of respiratory failure.
Question 3 of 5
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should encourage the patient to perform which of the following exercises to prevent complications?
Correct Answer: A
Rationale: The correct answer is A: Quadriceps setting exercises. These exercises help prevent complications by strengthening the quadriceps muscles, which are crucial for knee stability and joint support post-surgery. They also aid in preventing muscle atrophy and promoting blood circulation. Leg lifts with weights (B) may strain the knee joint, leading to complications. Isometric muscle contractions (C) involve static muscle contractions and do not provide the necessary range of motion needed post-knee surgery. Active range-of-motion exercises (D) may be beneficial but should be performed after quadriceps setting exercises to avoid unnecessary strain on the knee joint.
Question 4 of 5
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should monitor for which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Post-operative hip replacement patients are at high risk for DVT due to immobility and surgical trauma. The nurse should monitor for signs such as swelling, redness, and pain in the affected leg. DVT can lead to serious complications like pulmonary embolism if not detected early. Choices A, C, and D are incorrect because while pneumonia, wound infection, and hypoglycemia are also potential post-operative complications, they are not as directly associated with hip replacement surgery as DVT.
Question 5 of 5
Which of the following statements accurately reflects the concept of ethnicity?
Correct Answer: B
Rationale: The correct answer is B because ethnicity is defined by shared heritage, culture, language, or religion. This definition encompasses the key components that make up an individual's ethnic identity. Choice A is incorrect because while political forces may influence ethnicity, it does not define the concept itself. Choice C is incorrect as ethnicity is not necessarily related to belief in a higher power. Choice D is incorrect as ethnicity is not solely a learned behavior but also includes innate aspects like heritage.