ATI RN
hesi health assessment test bank Questions
Question 1 of 5
What is the priority nursing action when a client experiences a severe allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it acts quickly to reverse symptoms like airway swelling and low blood pressure. It helps to open airways and increase blood pressure. Antihistamines (B) are not as fast-acting as epinephrine in severe reactions. Applying a cold compress (C) is not effective in treating anaphylaxis. Placing the client in a supine position (D) can worsen breathing difficulties. Administering epinephrine is crucial in managing severe allergic reactions promptly and effectively.
Question 2 of 5
What should be monitored closely for a client receiving total parenteral nutrition?
Correct Answer: C
Rationale: Step-by-step rationale: 1. Total parenteral nutrition (TPN) can cause adrenal insufficiency. 2. Corticosteroids help prevent adrenal insufficiency in TPN patients. 3. Monitoring corticosteroid administration ensures adrenal function. 4. Monitoring blood glucose or serum glucose levels is important but not specific to TPN. 5. Dehydration can be monitored but is not directly related to TPN.
Question 3 of 5
What is a purpose of health assessment? (Select one that doesn't apply)
Correct Answer: A
Rationale: The correct answer is A because the purpose of health assessment is not solely to identify the client's major disease process. Health assessment also includes collecting information about the client's health status, clarifying their ability to pay for health care, and evaluating client outcomes. Identifying the disease process is just one component of a comprehensive health assessment. The other choices (B, C, D) are incorrect because they all represent valid purposes of health assessment. Collecting information about health status helps in understanding the client's overall well-being, clarifying the ability to pay for health care assists in planning appropriate care, and evaluating client outcomes is essential for monitoring progress and adjusting interventions as needed.
Question 4 of 5
What should the nurse do first when a client develops a fever postoperatively?
Correct Answer: A
Rationale: The correct answer is A: Administer antipyretics. The nurse should first address the fever to prevent potential complications. Antipyretics help reduce fever and discomfort quickly. Monitoring vital signs (B) is important but treating the fever takes precedence. Administering fluids (C) is essential, but addressing the fever is the priority. Administering IV antibiotics (D) may be necessary if the fever is due to infection, but confirming the cause and starting treatment can come after addressing the fever.
Question 5 of 5
What is the most important intervention for a client with severe burns?
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. This is the most important intervention for a client with severe burns because it helps maintain adequate fluid balance and prevent hypovolemic shock. IV fluids are crucial in managing burns to prevent complications such as dehydration and organ damage. Monitoring vital signs closely (B) and urine output (C) are important, but administering IV fluids takes precedence in stabilizing the client. Placing the client in a prone position (D) is not recommended for burn patients as it can increase the risk of infection and impede breathing.
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