ATI RN
hesi health assessment test bank Questions
Question 1 of 5
What should the nurse do first when a client is admitted with acute pain after surgery?
Correct Answer: A
Rationale: The correct first step is to administer pain relief (Choice A) because addressing the client's pain is a top priority to ensure their comfort and well-being. Pain management is crucial post-surgery to prevent complications and aid in recovery. Monitoring vital signs (Choice B) is important but should follow pain relief to ensure the client's stability. Assessing the wound (Choice C) is necessary but not the immediate priority when the client is in acute pain. Applying a warm compress (Choice D) may provide temporary relief but does not address the underlying cause of the pain. Therefore, administering pain relief is the most appropriate initial action to alleviate the client's discomfort and start the healing process effectively.
Question 2 of 5
Why might breast implants interfere with mammography?
Correct Answer: D
Rationale: The correct answer is D because breast implants can hinder mammography by obscuring the view of breast tissue, making it difficult to detect abnormalities like masses. This is due to the implants blocking the x-ray machine's view. Choice A is incorrect as discomfort is not the primary reason for interference. Choice B is incorrect as breast implants are not a contraindication to mammography but can complicate the process. Choice C is incorrect as implants are designed to be secure and are not likely to be dislodged during a mammogram.
Question 3 of 5
What is the appropriate response when a pregnant Asian client requests ginger for nausea?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Calling the physician shows respect for the client's request and ensures safety. 2. Consulting the physician is important to consider any potential contraindications. 3. Ginger is a common remedy for nausea and is safe for most pregnant individuals. 4. Collaborating with the physician ensures appropriate care for the client's specific needs. Summary of Incorrect Choices: - B: Dismissing home remedies may not align with the client's cultural beliefs or preferences. - C: Herbs can be effective and safe alternatives, and the client's request should be respected. - D: While dry crackers may help with nausea, they do not address the client's specific request for ginger.
Question 4 of 5
What is the priority nursing intervention for a client receiving chemotherapy?
Correct Answer: A
Rationale: The correct answer is A: Provide hydration. During chemotherapy, hydration is crucial to prevent dehydration and maintain kidney function. Chemotherapy drugs can be nephrotoxic and cause electrolyte imbalances. Hydration supports drug clearance and prevents kidney damage. Administering oxygen (B) is not typically a priority unless the client is experiencing respiratory distress. Administering pain medications (C) may be important but is not the priority over hydration. Monitoring for signs of infection (D) is important but providing hydration to prevent dehydration and maintain kidney function takes precedence.
Question 5 of 5
What is the priority action for a client with a suspected myocardial infarction?
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the priority action for a client with a suspected myocardial infarction as it helps dilate coronary arteries, improving blood flow to the heart muscle. This helps reduce chest pain and minimize myocardial damage. Administering fluids (B) may be necessary but not the priority. Placing the client in a sitting position (C) could worsen symptoms. Administering aspirin (D) is important but not as immediate as nitroglycerin for acute pain relief.
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