jarvis health assessment test bank

Questions 84

ATI RN

ATI RN Test Bank

jarvis health assessment test bank Questions

Question 1 of 5

What should the nurse prioritize for a client with suspected sepsis?

Correct Answer: B

Rationale: The correct answer is B: Administer antibiotics. In sepsis, timely administration of antibiotics is crucial to combat the underlying infection. Antibiotics target the bacteria causing the sepsis, helping to prevent further spread and worsening of the condition. Administering IV fluids (choice A) is important to maintain blood pressure, but antibiotics take precedence in treating the infection. Providing fluids (choice C) is also important but not the priority over antibiotics. Administering oxygen (choice D) may be necessary for respiratory support in severe cases of sepsis, but it does not address the root cause of the condition like antibiotics do.

Question 2 of 5

In recording the childhood illnesses of a patient, who denies having had any, which of the following notes by the nurse would be most accurate?

Correct Answer: D

Rationale: The correct answer is D because it provides a thorough list of specific childhood illnesses and confirms the patient's denial of having had them. This approach ensures comprehensive documentation and accuracy. Choice A is vague and lacks specificity, potentially leading to misunderstandings. Choice B focuses on the patient's perception of their health rather than actual illnesses. Choice C mentions the patient's sister and measles, which is irrelevant to the patient's own medical history. Overall, choice D is the most accurate and relevant option for documenting the patient's childhood illnesses.

Question 3 of 5

What should the nurse do when a client presents with a severe allergic reaction?

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. In severe allergic reactions, such as anaphylaxis, epinephrine is the first-line treatment as it rapidly reverses life-threatening symptoms like airway constriction and low blood pressure. Antihistamines (choice B) may help with mild symptoms but are not sufficient for severe reactions. Applying a cold compress (choice C) is not effective in treating anaphylaxis. Encouraging deep breathing (choice D) is not appropriate as the client may have difficulty breathing due to airway constriction. Administering epinephrine is crucial to quickly stabilize the client's condition in a severe allergic reaction.

Question 4 of 5

What is the most effective intervention for a client with a history of respiratory distress?

Correct Answer: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open airways, making it effective in treating respiratory distress. It works quickly to relieve symptoms such as shortness of breath and wheezing. Corticosteroids (B) may be used in conjunction with albuterol for severe cases, but albuterol is the immediate intervention. Providing pain relief (C) is not the primary intervention for respiratory distress. Nebulizers (D) are a delivery method for medications like albuterol, but the key intervention is administering the medication itself.

Question 5 of 5

The nurse has decided to administer the Set Test to Mr. C., age 70 years. To administer this test the nurse needs to:

Correct Answer: B

Rationale: The correct answer is B because the Set Test typically involves naming 10 items based on specific categories, such as those in the FACT acronym (Fruit, Animal, Color, and Town). The nurse should inform Mr. C. that he can complete the task without any hurry, which helps reduce stress and allows him to focus on recalling the items. This approach aligns with the standard administration procedure of the Set Test, promoting a relaxed and supportive environment for the patient. Choice A is incorrect because the nurse should not offer direct assistance or mention availability to help unless Mr. C. explicitly requests it. Choice C is incorrect as prompting the patient's memory may interfere with the natural cognitive process being assessed. Choice D is incorrect because imposing a time limit can induce unnecessary pressure and potentially affect the accuracy of the results.

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