ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
After having an argument with a spouse, which defense mechanism is the patient exhibiting when becoming verbally abusive toward the nurse?
Correct Answer: D
Rationale: The correct answer is D: Displacement. Displacement is the defense mechanism where emotions or impulses are redirected from the original target to a less threatening target. In this scenario, the patient is displacing their anger from their spouse onto the nurse. This is evident by the patient becoming verbally abusive towards the nurse after the argument with their spouse. A: Denial is the defense mechanism where individuals refuse to accept reality. This is not applicable in this situation as the patient is not denying the argument with their spouse. B: Projection is the defense mechanism where individuals attribute their own unacceptable thoughts or feelings onto someone else. This is not the case here as the patient is not attributing their behavior to the nurse. C: Sublimation is the defense mechanism where individuals channel their emotions into more socially acceptable behaviors. This is not relevant in this context as the patient is not channeling their emotions into a constructive outlet.
Question 2 of 5
The nurse understands that medication absorption is affected by the administration route. Which route for medications has the fastest absorption rate?
Correct Answer: B
Rationale: The correct answer is B: Intravenous (IV) injection. IV injection delivers medications directly into the bloodstream, bypassing the digestive system for immediate absorption. This route ensures the fastest onset of action as the medication is rapidly distributed throughout the body. Cream applied to the skin (A) undergoes slower absorption through the skin layers. Enteric-coated capsules (C) are designed to dissolve in the intestines, delaying absorption. Subcutaneous injection (D) involves slower absorption compared to IV due to the medication being injected into the fatty tissue under the skin.
Question 3 of 5
When the nurse is administering furosemide 40 mg IV push to a client in congestive heart failure (CHF), what phase of the nursing process does this represent?
Correct Answer: C
Rationale: The correct answer is C: Implementation. This is because administering furosemide 40 mg IV push to a client in CHF is an action that falls under the Implementation phase of the nursing process, where the nurse carries out the planned interventions to help achieve the client's goals. Assessment (A) is the data collection phase, Planning (B) involves setting goals and determining interventions, and Evaluation (D) is the phase where the nurse assesses the effectiveness of the interventions. In this case, actually administering the medication is executing the planned intervention, thus categorizing it under Implementation.
Question 4 of 5
Which flow sheet provides the health care provider with information on an ongoing record of fluid loss?
Correct Answer: D
Rationale: The correct answer is D, the Intake & Output (I&O) graphic sheet, as it provides a comprehensive record of fluid loss by documenting all fluids taken in and excreted by the patient. This is crucial for monitoring hydration status and detecting any imbalances. The Critical care flow sheet (A) focuses on critical care parameters, the Vital signs graphic sheet (B) records vital signs, and the Health assessment flow sheet (C) documents patient assessments. These choices do not specifically track fluid loss like the I&O graphic sheet does.
Question 5 of 5
Before administering a prescribed electrolyte supplement, the nurse reviews a client's electrolyte panel: What should the nurse do next?
Correct Answer: D
Rationale: The correct answer is D. Holding potassium chloride (KCl) and calling the healthcare provider (HCP) is crucial because administering electrolytes without proper assessment can be dangerous. If the electrolyte panel shows abnormal levels, especially for potassium, the nurse must seek guidance from the healthcare provider to prevent potential harm. Re-checking the client's basic metabolic panel (BMP) (choice A) may not provide specific information about the electrolyte imbalance. Administering calcium carbonate (choice B) may not address the specific electrolyte imbalance revealed in the panel. Administering potassium chloride (KCl) (choice C) without further assessment and guidance could worsen the imbalance.