ATI RN
health assessment exam 2 test bank Questions
Question 1 of 5
A nurse is caring for a patient with diabetes who is experiencing hypoglycemia. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In hypoglycemia, the priority is to quickly raise the patient's blood sugar levels to prevent potential complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (A) would further lower blood sugar levels, worsening the situation. Administering an oral hypoglycemic agent (C) is not appropriate in an acute hypoglycemic episode. Monitoring blood pressure (D) is important but not the priority in this situation.
Question 2 of 5
During an interview, a woman says, "I just know labour will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labour." The nurse responds by stating, "Oh, don't worry about labour so much. I have been through it myself, and yes, it is painful, but there are many good medications to decrease the pain." Which of the following statements about this response is true?
Correct Answer: B
Rationale: The correct answer is B: It was a nontherapeutic response. The nurse responded in a way that downplayed the patient's concerns and shut down the conversation. Rationale: 1. The nurse's response of dismissing the woman's fear and immediately shifting the focus to medication options invalidates the woman's feelings. 2. By sharing her own experience without acknowledging the woman's emotions, the nurse fails to provide genuine support. 3. The response lacks empathy and fails to address the woman's emotional needs, thus hindering effective communication. 4. This type of response may discourage the woman from expressing her concerns openly in the future, leading to potential emotional distress. Summary of other choices: A: Incorrect. Sharing personal experience alone does not make it therapeutic. In this context, it did not address the woman's emotional concerns effectively. C: Incorrect. Providing information about medications, although helpful, does not address the woman's emotional distress and fears. D: Incorrect. While the response did minimize the patient
Question 3 of 5
A nurse is teaching a patient with diabetes about the importance of controlling blood glucose levels. Which of the following statements by the patient indicates the need for further education?
Correct Answer: B
Rationale: The correct answer is B because stopping insulin when blood sugar is normal can lead to hyperglycemia. A: Monitoring blood sugar is essential for diabetes management. C: Eating balanced diet and exercising help control blood sugar levels. D: Avoiding sugary foods is important to manage blood sugar.
Question 4 of 5
A nurse is caring for a patient with chronic heart failure. Which of the following interventions should the nurse prioritize?
Correct Answer: A
Rationale: The correct answer is A: Administering diuretics as prescribed. Diuretics help reduce fluid retention in patients with heart failure, relieving symptoms like edema and shortness of breath. Prioritizing diuretics can help manage the patient's fluid balance and improve heart function. Encouraging increased fluid intake (B) is contraindicated as it can worsen fluid overload. Restricting sodium intake (C) is important in heart failure management but not the top priority over administering diuretics. Administering pain medications (D) is not a priority intervention for chronic heart failure management.
Question 5 of 5
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should monitor for signs of which of the following complications?
Correct Answer: C
Rationale: The correct answer is C: Deep vein thrombosis (DVT). After knee replacement surgery, the patient is at a higher risk for developing DVT due to immobility and altered blood flow. Monitoring for signs such as calf pain, swelling, and redness is crucial to prevent complications like pulmonary embolism. Pulmonary embolism (Choice A) is a potential complication of untreated DVT. Gastrointestinal bleeding (Choice B) is not directly related to knee replacement surgery. Hypoglycemia (Choice D) is not a common complication post-knee replacement. Monitoring for DVT is essential in preventing life-threatening complications for the patient.
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