ATI RN
test bank for health assessment Questions
Question 1 of 5
What should a nurse prioritize for a client with a history of chronic obstructive pulmonary disease (COPD) who is experiencing an exacerbation?
Correct Answer: B
Rationale: Correct Answer: B - Administer oxygen Rationale: 1. Oxygen therapy is crucial in managing COPD exacerbation to improve oxygen saturation levels. 2. Adequate oxygenation is essential to prevent further respiratory distress and potential complications. 3. Oxygen therapy helps alleviate symptoms like shortness of breath and fatigue, improving overall comfort. 4. Monitoring oxygen saturation levels guides the effectiveness of treatment and ensures appropriate oxygen delivery. Summary: - Administering corticosteroids (A) may help reduce inflammation in COPD exacerbation but does not address the immediate need for oxygen. - Monitoring respiratory rate (C) is important but prioritizing oxygen administration is more critical for immediate respiratory support. - Administering diuretics (D) may be indicated in certain cases of COPD exacerbation with fluid retention but is not the priority over oxygen therapy.
Question 2 of 5
What type of assessment occurs in emergency situations?
Correct Answer: D
Rationale: In emergency situations, time is crucial. Emergency assessment is the most appropriate as it focuses on quickly identifying and addressing life-threatening issues. It involves a rapid but systematic evaluation of the patient's airway, breathing, circulation, and disability. Head-to-toe assessment (A) and comprehensive assessment (C) are too time-consuming in emergencies, whereas focused assessment (B) may not cover all critical aspects.
Question 3 of 5
Which of the following signs and symptoms is indicative of a post-operative wound infection?
Correct Answer: B
Rationale: The correct answer is B: Tenderness, warmth, and swelling at the site. Post-operative wound infection often presents with localized tenderness, warmth, and swelling due to inflammation and immune response. Redness, heat, and purulent drainage (choice A) can also indicate infection but are not specific to wound infections. Excessive swelling and redness (choice C) may be present in inflammatory responses but do not specifically point to an infection. Fever, chills, and nausea (choice D) can be systemic signs of infection but are not specific to wound infections. Tenderness, warmth, and swelling are more indicative of a localized wound infection.
Question 4 of 5
What should the nurse do first when a client is experiencing an allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for an allergic reaction as it helps to reverse severe symptoms like swelling, difficulty breathing, and low blood pressure. Administering epinephrine promptly can prevent the allergic reaction from escalating into a life-threatening situation. Antihistamines (choice B) may be given after epinephrine for symptom relief but are not as immediate in action. Monitoring vital signs (choice C) is important, but administering epinephrine takes precedence in managing the allergic reaction. Providing a cold compress (choice D) may help with local swelling but does not address the systemic effects of the allergic reaction.
Question 5 of 5
What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36 mmHg, and HCO3 24 mEq/L?
Correct Answer: B
Rationale: The given ABG values fall within normal ranges, indicating homeostasis. The pH is within the normal range (7.35-7.45), indicating acid-base balance. The PO2 is slightly lower but still within the normal range (80-100 mmHg). PCO2 falls within the normal range (35-45 mmHg), showing effective ventilation. The HCO3 level is also within the normal range (22-26 mEq/L), indicating proper kidney function. Therefore, all values are within normal limits, reflecting a state of homeostasis. Other choices are incorrect as they suggest imbalances in acid-base status, which is not seen with these values.
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