ATI RN
health assessment test bank Questions
Question 1 of 9
Why must a nurse avoid disrupting bloodstains or tears on the clothing of a trauma client?
Correct Answer: C
Rationale: The correct answer is C because the clothing of a trauma client could potentially be considered evidence with legal implications. Preserving the bloodstains or tears on the clothing maintains the integrity of the evidence for forensic investigation or legal proceedings. Disrupting the bloodstains or tears could compromise the evidence and hinder any potential investigation or legal case. Choices A, B, and D are incorrect because the primary concern in this scenario is the legal implications and preservation of evidence, not ownership, repair, salvage, or minimizing trauma to family members.
Question 2 of 9
A nurse is caring for a patient who is post-operative following an abdominal surgery. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation to prevent deep vein thrombosis. Early ambulation helps prevent blood clot formation in the legs, reducing the risk of deep vein thrombosis post-surgery. It also promotes circulation and aids in preventing complications like pneumonia. Administering pain medication (B) is important, but preventing complications should take priority. Providing wound care (C) is essential but not the top priority. Encouraging a high-protein diet (D) is beneficial for healing, but immediate post-operative mobility is crucial for preventing complications.
Question 3 of 9
The major electrolytes in the extracellular fluid are:
Correct Answer: C
Rationale: The correct answer is C: sodium and chloride. In the extracellular fluid, sodium and chloride are the major electrolytes due to their roles in maintaining fluid balance, nerve function, and muscle contraction. Potassium and phosphate (choice B) are primarily found in intracellular fluid, while potassium and chloride (choice A) are not the major electrolytes in extracellular fluid. Similarly, sodium and phosphate (choice D) are not major extracellular electrolytes. Thus, choice C is the correct answer based on the significant presence and functions of sodium and chloride in the extracellular fluid.
Question 4 of 9
The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?
Correct Answer: B
Rationale: Step 1: The nurse should prioritize collecting data based on the client's acuity to address immediate needs and ensure patient safety. Step 2: Acuity determines the urgency and intensity of care required, guiding the assessment focus. Step 3: Time available or client cooperation may influence the depth of assessment but do not dictate the data collected. Step 4: The onset of symptoms is important for history-taking but not the primary factor in determining assessment data.
Question 5 of 9
A nurse is teaching a patient with asthma about managing asthma attacks. Which of the following statements by the patient indicates proper understanding?
Correct Answer: A
Rationale: Correct Answer: A Rationale: Using the inhaler when feeling an asthma attack coming on allows for prompt relief by opening airways. Waiting for symptoms to worsen (B) can lead to a severe attack. Using the inhaler only when short of breath (C) may delay treatment. Skipping the inhaler when feeling fine (D) can be dangerous if an attack occurs suddenly. Answer A ensures timely intervention for effective asthma management.
Question 6 of 9
A patient is at the clinic to have her blood pressure checkeShe has been coming to the clinic weekly since her medications were changed 2 months ago. The nurse should:
Correct Answer: A
Rationale: Rationale: 1. Collecting a follow-up database ensures up-to-date information. 2. It allows for monitoring of medication effectiveness and any new symptoms. 3. Checking the blood pressure is essential but needs current context. 4. Asking the patient to read her record may not provide all necessary updates. 5. The complete health history is crucial but obtaining it first may delay urgent blood pressure check.
Question 7 of 9
What is the most appropriate action for a client with a history of asthma who is experiencing wheezing?
Correct Answer: A
Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open the airways, relieving wheezing in asthma patients. It is the first-line treatment for acute asthma exacerbations. Antihistamines (B) do not treat asthma symptoms. Monitoring for infection (C) is important but not the immediate action for wheezing. Epinephrine (D) is used for severe allergic reactions, not routine asthma management.
Question 8 of 9
What is the most appropriate action when a client with suspected meningitis presents with a positive Brudzinski sign?
Correct Answer: D
Rationale: The correct answer is D, perform a lumbar puncture. A positive Brudzinski sign indicates meningeal irritation, a hallmark of meningitis. A lumbar puncture is the gold standard for diagnosing meningitis by analyzing cerebrospinal fluid. Placing the client on their back without proper diagnosis or treatment delays could lead to serious complications. Option B is incorrect as antibiotics should be given after confirming the diagnosis. Option C is partially correct but does not address the need for a definitive diagnostic test. Option A is incorrect as pain medication alone does not address the underlying cause of meningitis.
Question 9 of 9
What is the best way to assess a client's nutritional status?
Correct Answer: B
Rationale: The correct answer is B: Monitoring serum albumin levels. This is because serum albumin is a protein synthesized by the liver that reflects long-term protein intake and overall nutritional status. Low levels indicate malnutrition or inflammation. Obtaining a dietary history (choice A) is important but may not always reflect the actual nutritional status. Monitoring weight (choice C) is helpful but may not provide a comprehensive view of the client's nutritional status. Providing a meal plan (choice D) is a proactive approach but does not directly assess the client's current nutritional status.