ATI RN
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Question 1 of 5
What should the nurse prioritize for a client who is at risk for developing a blood clot after surgery?
Correct Answer: A
Rationale: The correct answer is A: Administer anticoagulants. This is crucial for preventing blood clots post-surgery as they help thin the blood and reduce clot formation. Monitoring for arrhythmias (B) is important but not the priority in this case. While encouraging deep breathing (C) and fluid intake (D) are beneficial for post-surgical recovery, they do not directly address the risk of blood clot formation. Administering anticoagulants is the most effective intervention to prevent blood clots in high-risk surgical patients.
Question 2 of 5
A patient is found to have an irregular, jagged scar that is raised and red. The nurse would classify this as:
Correct Answer: B
Rationale: The correct answer is B: Hypertrophic scar. This type of scar is raised, red, and irregular, but it does not extend beyond the boundaries of the original wound like a keloid. A keloid is characterized by excessive scar tissue that grows beyond the wound site. Contracture is a scar that causes tightening of the skin and may restrict movement. Stretch marks, on the other hand, are not raised or irregular like the described scar.
Question 3 of 5
A nurse is caring for a patient with diabetes who is receiving insulin. The nurse should be most concerned if the patient experiences:
Correct Answer: C
Rationale: The correct answer is C: Dizziness and shakiness. This indicates hypoglycemia, a potential side effect of insulin therapy. Dizziness and shakiness are classic signs of low blood sugar levels, which can be dangerous if left untreated. Headache and blurred vision (Option A) can occur with high blood sugar. Increased thirst and urination (Option B) are symptoms of hyperglycemia. Dry mouth and skin (Option D) are not immediate concerns related to insulin therapy.
Question 4 of 5
Which of the following is the most important intervention for a client with hypovolemic shock?
Correct Answer: A
Rationale: The correct answer is A: Administer fluids. In hypovolemic shock, the primary issue is a lack of circulating blood volume. Administering fluids helps to restore blood volume and improve perfusion to vital organs, addressing the underlying cause of shock. Vasopressors (B) are used in distributive shock, sodium bicarbonate (C) is used for metabolic acidosis, and corticosteroids (D) are typically not indicated in hypovolemic shock. Administering fluids is the most important intervention to stabilize the client's condition in hypovolemic shock.
Question 5 of 5
A nurse is caring for a patient with diabetes who is experiencing symptoms of hypoglycemia. The nurse should:
Correct Answer: B
Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. This is because in hypoglycemia, the patient's blood sugar levels are low and need to be raised quickly to avoid serious complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (choice A) would further lower blood sugar levels, monitoring without intervention (choice C) could lead to worsening symptoms, and administering an oral hypoglycemic agent (choice D) may not act quickly enough to raise blood sugar levels in an emergency situation.
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