ATI RN
hesi health assessment test bank Questions
Question 1 of 5
What should the nurse do when a client develops a deep vein thrombosis (DVT)?
Correct Answer: A
Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants help prevent the blood clot from getting larger and reduce the risk of it breaking loose and causing a pulmonary embolism. Other choices are incorrect because B: Monitoring vital signs alone does not treat the DVT, C: Providing bed rest can increase the risk of complications like pulmonary embolism, and D: Administering fibrinolytics is not the first-line treatment for DVT.
Question 2 of 5
What is the priority action for a client who has just undergone a craniotomy?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. After a craniotomy, the client may experience decreased oxygen levels due to the surgical procedure, anesthesia, or potential complications. Administering oxygen helps ensure adequate oxygenation to the brain and tissues. Placing the client in a supine or Trendelenburg position can increase intracranial pressure, which is contraindicated post-craniotomy. Monitoring for arrhythmias is important, but ensuring oxygenation takes precedence as hypoxia can have immediate detrimental effects on brain function.
Question 3 of 5
Which lab value is associated with the early detection of renal failure?
Correct Answer: A
Rationale: The correct answer is A: Creatinine. Creatinine is a waste product produced by muscles and excreted by the kidneys. An elevated creatinine level indicates impaired kidney function, making it a key indicator for early detection of renal failure. Blood urea nitrogen (BUN) can also be elevated in renal failure, but creatinine is a more specific and sensitive marker. Sodium and potassium levels are not directly related to renal failure detection.
Question 4 of 5
What is the most important nursing intervention for a client with congestive heart failure (CHF)?
Correct Answer: A
Rationale: The correct answer is A: Administer diuretics. Diuretics help reduce fluid overload in CHF by increasing urine output and decreasing the workload on the heart. This intervention addresses the underlying issue of fluid retention, a common problem in CHF. Monitoring vital signs (B) is important but does not directly target the primary problem of fluid overload. Monitoring respiratory rate (C) is essential in CHF, but administering diuretics takes precedence in managing fluid balance. Monitoring for arrhythmias (D) is important, but not the most crucial intervention in the management of CHF.
Question 5 of 5
What should be the nurse's first action when a client develops signs of hypovolemic shock?
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. In hypovolemic shock, there is a significant decrease in blood volume leading to inadequate perfusion of tissues. Administering IV fluids helps to restore circulating volume and improve tissue perfusion, which is crucial in managing hypovolemic shock. Elevating the client's legs (B) may be beneficial in other types of shock but not specifically in hypovolemic shock. Administering pain relief (C) and corticosteroids (D) are not the priority in hypovolemic shock as they do not address the underlying issue of decreased blood volume and tissue perfusion.
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