ATI RN
Stage Theories of Health Behavior Questions
Question 1 of 5
Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
Correct Answer: B
Rationale: The correct answer is B: Pallor, tachycardia, and a sore tongue. In pernicious anemia, the body lacks intrinsic factor needed for vitamin B12 absorption, leading to megaloblastic anemia. Pallor is a common symptom due to decreased red blood cells. Tachycardia occurs as the heart compensates for decreased oxygen-carrying capacity. A sore tongue, known as glossitis, is a classic sign of B12 deficiency. Choices A, C, and D do not align with typical manifestations of pernicious anemia.
Question 2 of 5
A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to perform pursed lip breathing. This is the appropriate step because the client with emphysema showing restlessness and confusion may be experiencing hypoxia. Pursed lip breathing helps improve oxygenation by slowing down breathing and facilitating better gas exchange. Checking the client's temperature (B) is not the priority in this situation. Assessing the client's potassium level (C) may be important but not the immediate step for a client showing signs of hypoxia. Increasing the client's oxygen flow rate (D) can be considered after assessing the client's response to pursed lip breathing.
Question 3 of 5
Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:
Correct Answer: B
Rationale: The correct answer is B (28 gtt/min). To calculate the flow rate in drops per minute (gtt/min), we use the formula: Flow rate (gtt/min) = Volume to be infused (ml) x Drop factor / Time (minutes). In this case, Mario needs 2 liters of IV fluid over 48 hours, which is 2000 ml over 2880 minutes. Using the given drop factor of 10 gtt/ml, we have: 2000 ml x 10 gtt/ml / 2880 min = 20,000 gtt / 2880 min = 6.94 gtt/min. To administer the 2 liters of fluid over 48 hours q12 h, we divide 6.94 gtt/min by 2 (since it's given q12 h) to get 3.47 gtt/min. Rounding up gives us 4 gtt/min for each 12-hour interval. Therefore
Question 4 of 5
Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating the her kidneys, the nurse should keep which anatomical fact in mind?
Correct Answer: A
Rationale: The correct answer is A because the left kidney is typically positioned slightly higher than the right one due to the space occupied by the liver on the right side. This anatomical fact is crucial for accurate palpation. Choice B is incorrect because the kidneys are actually located above the waist, not just above the adrenal glands. Choice C is incorrect as the average kidney size is around 11-14 cm long and 5-7.5 cm wide. Choice D is incorrect as the kidneys are located lower, between the 12th thoracic and the 3rd lumbar vertebrae.
Question 5 of 5
Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
Correct Answer: B
Rationale: The correct answer is B because a urine output of 20 ml/hour indicates potential hypovolemia or inadequate perfusion, which can lead to poor tissue perfusion and compromised healing in burn patients. This finding suggests a need for intervention to optimize fluid balance and prevent complications. A: A PaO2 value of 80 mm Hg can be within normal limits and does not specifically indicate a problem related to burns. C: White pulmonary secretions may suggest pulmonary infection but may not directly relate to the burns. D: A rectal temperature of 100.6°F (38°C) is slightly elevated and may be a normal response to the body's inflammatory process after burns, not necessarily indicating a problem.