NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect. Based on his developmental stage, the nurse:
Correct Answer: B
Rationale: A toddler is not capable of conceptualizing about the inside of his body and is concerned about body intactness; therefore, diagrams would not be useful. Also, the previous evening is too far from the procedure for the toddler to remember the instructions. A simple explanation the morning of the procedure is the best developmental strategy to use, because it focuses on the toddler's need for parental support, body intactness, and short attention span. A relationship between the nurse and the child needs to develop. Also, misinformation may be given to the child if the parents explain the procedure to the child. The parents are the child's support system and need to be there to strengthen the child.
Question 2 of 5
The nurse has just received the change of shift report. Which client should the nurse assess first?
Correct Answer: A
Rationale: The client two hours post-lobectomy with 150mL of chest drainage is at risk for complications such as hemorrhage or tension pneumothorax, requiring immediate assessment. The other clients are stable: scant drainage is expected post-gastrectomy, a fever in pneumonia is concerning but less urgent, and a fractured hip in traction is typically stable.
Question 3 of 5
The nurse instructs a client on the difference between true labor and false labor. The nurse explains, 'In true labor:
Correct Answer: B
Rationale: In true labor, uterine contractions strengthen and become more regular with activity like walking, facilitating cervical dilation and fetal descent.
Question 4 of 5
A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as 'a cramp in my leg.' An appropriate nursing action is to:
Correct Answer: B
Rationale: Calf pain with dorsiflexion of the foot (Homans' sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. A pillow behind the knee can be constricting and further impair blood flow.
Question 5 of 5
The physician has ordered atropine sulfate 0.4 milligrams IM before surgery. The medication is supplied in 0.8 milligrams per milliliter. How much medication should the nurse prepare to administer?
Correct Answer: 0.5
Rationale:
To calculate: 0.4 mg desired ÷ 0.8 mg/mL = 0.5 mL. The nurse should prepare 0.5 mL of atropine sulfate.