ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
Correct Answer: D
Rationale: The correct answer is D. First, the nurse should put the implant back in place using forceps and a shield for self-protection. This is important to limit the exposure to radiation for both the client and the nurse. Second, the nurse should call for help to ensure proper handling and further assistance. Standing away from the implant (choice
A) does not address the immediate need to secure the implant. Picking up the implant with long-handled forceps and placing it in a lead-lined container (choice
B) should only be done by trained personnel to prevent further exposure. Leaving the room and notifying the radiation therapy department immediately (choice
C) delays the immediate action needed to prevent unnecessary radiation exposure.
Question 2 of 5
Which of the following intravenous solutions is hypotonic?
Correct Answer: C
Rationale: The correct answer is C: 0.45% saline. This solution is hypotonic because it has a lower osmolarity compared to the intracellular fluid. It contains fewer solutes than the cells, causing water to move into the cells by osmosis, potentially causing them to swell.
Normal saline (
A) and Ringer's lactate (
B) are isotonic solutions, meaning they have a similar osmolarity to the intracellular fluid and do not cause significant water shifts.
5% dextrose in normal saline (
D) is a hypertonic solution, containing more solutes than the cells, leading to water movement out of the cells.
Question 3 of 5
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
Correct Answer: B
Rationale:
Step-by-step rationale for choice B being correct:
1. Blood pressure is vital in this scenario due to prednisone discontinuation.
2. Abruptly stopping prednisone can lead to adrenal insufficiency.
3. Adrenal insufficiency can cause hypotension, a life-threatening condition.
4. Monitoring blood pressure can help detect and manage potential complications.
Summary of other choices:
A: Breath sounds – Important but not the priority in this specific situation.
C: Capillary refill – Useful for assessing circulation but not urgent in this context.
D: Butterfly rash – A characteristic of lupus, but not a critical concern in this scenario.
Question 4 of 5
A client is receiving the cell cycle-nonspecific alkylating agent thiotepa (thioplex), 60 mg weekly for 4 weeks by bladder instillation as part of a chemotherapeutic regimen to treat bladder cancer. The client asks the nurse how the drug works. How does thiotepa exert its therapeutic effects?
Correct Answer: C
Rationale: The correct answer is C because thiotepa is a cell cycle-nonspecific alkylating agent that interferes with both DNA replication and RNA transcription. Thiotepa works by cross-linking DNA strands, leading to inhibition of DNA replication and transcription, ultimately causing cell death. This mechanism of action makes it effective against actively dividing cells, such as cancer cells.
Choice A is incorrect because thiotepa does not interfere with DNA replication alone.
Choice B is incorrect because thiotepa affects both DNA replication and RNA transcription, not just RNA transcription.
Choice D is incorrect because thiotepa does not destroy the cell membrane; instead, it acts on the genetic material within the cell.
Question 5 of 5
Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
Correct Answer: A
Rationale:
Step 1: Orthopnea is a classic symptom of congestive heart failure (CHF) due to fluid accumulation in the lungs when lying flat.
Step 2: This symptom occurs because when lying down, the fluid redistributes, making it harder to breathe.
Step 3: Fever (choice
B) is not typically associated with CHF unless there is an underlying infection.
Step 4: Weight loss (choice
C) is more indicative of conditions like cancer or malnutrition, not CHF.
Step 5: Calf pain (choice
D) is more commonly associated with deep vein thrombosis, not CHF.
Summary: Orthopnea is the best assessment finding indicating CHF, while the other choices are more likely related to different health conditions.