ATI RN
jarvis health assessment test bank Questions
Question 1 of 5
What is the most important nursing intervention for a client with an open fracture?
Correct Answer: A
Rationale: The correct answer is A: Apply a sterile dressing. This is the most important intervention to prevent infection and protect the wound. Applying a sterile dressing helps maintain a clean environment, reduces the risk of contamination, and promotes wound healing. Administering fluids (B) may be necessary but is not the top priority. Administering IV antibiotics (C) may be required but is secondary to wound care. Monitoring for bleeding (D) is important but addressing the wound with a sterile dressing takes precedence to prevent infection.
Question 2 of 5
A nurse is caring for a patient with chronic kidney disease (CKD). The nurse should prioritize which of the following interventions?
Correct Answer: C
Rationale: The correct answer is C because monitoring kidney function with regular laboratory tests is crucial in managing CKD. Regular testing helps identify changes in kidney function early, allowing for timely interventions to prevent complications. Administering diuretics (choice A) may worsen kidney function. Encouraging weight loss (choice B) may be necessary, but monitoring kidney function takes precedence. Encouraging the patient to limit fluid intake (choice D) may be necessary in some cases, but it is not the priority intervention.
Question 3 of 5
What is the most effective action when a client with a history of stroke develops difficulty speaking?
Correct Answer: B
Rationale: The correct answer is B: Administer thrombolytics. Thrombolytics help dissolve blood clots, which may be causing the stroke. Administering thrombolytics promptly can improve blood flow to the brain, potentially reducing the severity of the stroke and its effects, including difficulty speaking. Calling for help (A) is important, but administering thrombolytics should be a priority. Performing a CT scan (C) may help confirm the type of stroke but may delay immediate treatment. Administering bronchodilators (D) is not indicated for difficulty speaking related to stroke.
Question 4 of 5
A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which of the following is a common sign of COPD exacerbation?
Correct Answer: B
Rationale: The correct answer is B: Increased shortness of breath. During a COPD exacerbation, airflow limitation worsens, leading to increased difficulty in breathing. This is a common sign due to air trapping and inflammation in the airways. Sudden weight gain (A) is not typically associated with COPD exacerbation. Decreased heart rate (C) is not a common sign and is more likely to occur in other conditions. Increased energy levels (D) are unlikely during a COPD exacerbation as the body is under stress from impaired lung function.
Question 5 of 5
A nurse is caring for a patient with a history of stroke. The nurse should monitor for signs of which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis. Patients with a history of stroke are at an increased risk of developing deep vein thrombosis due to immobility and vascular damage. This complication can lead to serious consequences, such as pulmonary embolism. Monitoring for signs of deep vein thrombosis, such as leg swelling and pain, is crucial for early detection and intervention. Severe dehydration (A), liver failure (C), and pulmonary embolism (D) are less likely complications in a patient with a history of stroke compared to deep vein thrombosis.
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