ATI RN
hesi health assessment test bank Questions
Question 1 of 5
Which condition places a client at risk for a high ammonia level?
Correct Answer: D
Rationale: The correct answer is D: cirrhosis. Cirrhosis leads to impaired liver function, causing the liver to be unable to effectively metabolize ammonia, leading to high ammonia levels in the blood. Renal failure (choice A) is associated with high creatinine levels, not ammonia. Psoriasis (choice B) is a skin condition unrelated to ammonia levels. Lupus (choice C) is an autoimmune disease affecting various organs, not directly linked to high ammonia levels. In summary, cirrhosis is the only condition among the options that directly impacts liver function and can lead to high ammonia levels in the blood.
Question 2 of 5
During a physical assessment, which type of data is collected?
Correct Answer: C
Rationale: The correct answer is C: Objective. Objective data in a physical assessment refers to measurable and observable information obtained through physical examination, laboratory tests, and diagnostic procedures. This type of data is crucial as it is based on facts and can be quantified. Subjective data (A) is based on the patient's feelings and experiences, while patient-centered (B) refers to care that is tailored to the individual's preferences. Diagnostic (D) data refers to information obtained through tests to determine a specific condition, which is different from the general data collected during a physical assessment.
Question 3 of 5
What is the most effective intervention for a client with shortness of breath and a history of heart failure?
Correct Answer: B
Rationale: The correct answer is B: Provide oxygen therapy. For a client with shortness of breath and a history of heart failure, oxygen therapy is the most effective intervention as it helps improve oxygenation and relieve respiratory distress. Administering diuretics may help manage fluid retention but does not directly address the breathing difficulty. Encouraging deep breathing may be beneficial for some respiratory conditions but may not be sufficient for a client with heart failure and shortness of breath. Applying oxygen therapy is similar to providing oxygen therapy and can help improve oxygen levels, but providing oxygen therapy is more specific and effective in this case.
Question 4 of 5
What is the priority nursing action when a client experiences a severe allergic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it acts quickly to reverse symptoms like airway swelling and low blood pressure. It helps to open airways and increase blood pressure. Antihistamines (B) are not as fast-acting as epinephrine in severe reactions. Applying a cold compress (C) is not effective in treating anaphylaxis. Placing the client in a supine position (D) can worsen breathing difficulties. Administering epinephrine is crucial in managing severe allergic reactions promptly and effectively.
Question 5 of 5
Which positions are appropriate for clients with dumping syndrome and GERD after meals?
Correct Answer: B
Rationale: Rationale: 1. GERD: Lying down after eating can worsen symptoms due to acid reflux. Sitting up helps prevent acid reflux. 2. Dumping Syndrome: Lying down can exacerbate symptoms like nausea and dizziness. Sitting up aids in digestion. 3. Choice B recommends lying down 1 hour after eating for Dumping Syndrome and sitting up at least 30 minutes after eating for GERD, which aligns with the management of both conditions. Summary: - Choice A is incorrect as lying flat after meals worsens GERD and Dumping Syndrome symptoms. - Choice C is incorrect as sitting up only after meals does not address the specific needs of GERD and Dumping Syndrome. - Choice D is incorrect as lying down after meals is not recommended for either condition.
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