test bank for health assessment

Questions 47

ATI RN

ATI RN Test Bank

test bank for health assessment Questions

Question 1 of 5

What should the nurse do when caring for a client who is experiencing an anaphylactic reaction?

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it helps to quickly reverse severe symptoms by constricting blood vessels and opening airways. Administering corticosteroids (B) is not the immediate priority. Placing the client on their side (C) is important to prevent aspiration but does not address the anaphylactic reaction. Monitoring blood pressure (D) is essential but administering epinephrine takes precedence in managing anaphylaxis.

Question 2 of 5

What should the nurse do first for a client who is post-operative and experiences confusion?

Correct Answer: A

Rationale: The correct answer is A: Reorient the client. This is the first step because confusion post-operatively could be due to anesthesia, pain medications, or disorientation. Reorienting the client helps bring them back to reality and decrease anxiety. B: Monitoring for signs of infection would be important but not the initial step for confusion. C: Monitoring serum electrolytes is important but not the immediate priority for confusion. D: Applying a cold compress is not relevant for confusion in a post-operative client.

Question 3 of 5

What should the nurse do first when caring for a client with chest pain?

Correct Answer: A

Rationale: The nurse should first administer aspirin to a client with chest pain as it helps prevent blood clot formation during a possible heart attack. Aspirin inhibits platelet aggregation, reducing the risk of further blockage in the coronary arteries. Administering aspirin promptly can improve the client's outcomes. Performing an ECG, monitoring vital signs, or providing a meal plan are important but should come after administering aspirin in the initial management of chest pain to prioritize the client's safety and well-being.

Question 4 of 5

Which goal should be set for a client at risk for nutritional problems?

Correct Answer: B

Rationale: The correct answer is B: Increase weight. For a client at risk for nutritional problems, increasing weight is crucial to improve overall health and address potential malnutrition. This goal focuses on restoring and maintaining a healthy weight, which is essential for proper functioning of the body and reducing the risk of various health issues. Promoting healthy nutritional practices (choice A) is important but may not address the immediate need for weight gain. Treating complications of malnutrition (choice C) is reactive rather than proactive. Increasing protein in the diet (choice D) is helpful but not comprehensive enough to address the overall nutritional needs of the client.

Question 5 of 5

What is the priority nursing action for a client with suspected hypovolemic shock?

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In hypovolemic shock, the body lacks adequate circulating blood volume leading to decreased tissue perfusion and oxygen delivery. Administering oxygen helps increase oxygen saturation levels and improve tissue oxygenation. This is the priority nursing action to ensure the client's vital organs receive sufficient oxygen. Administering pain relief (B) may be necessary but is not the priority in hypovolemic shock. Administering beta blockers (C) can further decrease blood pressure and worsen the condition. Monitoring for bleeding (D) is important, but administering oxygen takes precedence to address the immediate oxygenation needs of the client.

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