ATI RN
Theoretical Basis for Behavior Modification Questions
Question 1 of 5
Nurse Sugar is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?
Correct Answer: B
Rationale: The correct answer is B: An irregular apical pulse. In Cushing's syndrome, excess cortisol can lead to cardiac arrhythmias. An irregular apical pulse indicates potential cardiac issues requiring immediate attention. Pitting edema (A) is common in conditions like heart failure. Dry mucous membranes (C) can be due to dehydration. Frequent urination (D) can be caused by conditions like diabetes. However, an irregular pulse is the most urgent concern due to the risk of serious cardiac complications.
Question 2 of 5
If a client requires a pneumonectomy, what fills the area of the thoracic cavity?
Correct Answer: C
Rationale: The correct answer is C because after a pneumonectomy, the pleural cavity is filled with serous fluids to prevent collapse and consolidate the region. This fluid helps maintain the integrity of the thoracic cavity structure and prevents the other organs from shifting. Choice A is incorrect because leaving the space filled with air would lead to a collapsed lung and inefficient breathing. Choice B is incorrect as filling the space with a gel would not serve any physiological purpose and could potentially cause complications. Choice D is incorrect as tissue from the other lung does not grow over to the other side to fill the empty space left by the removed lung.
Question 3 of 5
Francis with leukemia has neutropenia. Which of the following functions must frequently assessed?
Correct Answer: D
Rationale: The correct answer is D: Breath sounds. In a patient with neutropenia, there is a higher risk of developing respiratory infections due to low white blood cell count. Assessing breath sounds can help detect early signs of respiratory distress or infection, which can be life-threatening in this population. Blood pressure (A), bowel sounds (B), and heart sounds (C) are important assessments, but in the context of neutropenia, monitoring breath sounds is crucial for early detection and intervention in respiratory complications.
Question 4 of 5
During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take is:
Correct Answer: C
Rationale: The correct answer is C: Immediately discontinue the infusion. This action is necessary to prevent further harm to the patient in case of an adverse reaction to the chemotherapy agent. Discontinuing the infusion will stop the administration of the potentially harmful drug and allow for prompt assessment and intervention. Notifying the physician (choice A) can be done after discontinuing the infusion. Flushing the IV line (choice B) may not address the underlying issue of the redness and swelling at the site. Applying an ice pack followed by warm compress (choice D) may provide temporary relief but does not address the need to stop the infusion immediately.
Question 5 of 5
When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best action would be:
Correct Answer: D
Rationale: The correct answer is D because frequent bowel movements can help reduce sodium levels in cases of diarrhea caused by lactose intake. Lactose intolerance can lead to osmotic diarrhea due to the unabsorbed lactose drawing water into the intestines. By encouraging frequent bowel movements, excess sodium is excreted along with the watery stools, helping to restore electrolyte balance. Choice A is incorrect because contacting the physician immediately is not necessary in this situation as the nurse can take appropriate action. Choice B is incorrect because withholding the drug may not address the root cause of the diarrhea. Choice C is incorrect because simply lowering the dosage may not be sufficient to address the diarrhea effectively.