NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:
Correct Answer: A
Rationale: Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and survival is likely.
Question 2 of 5
An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
Correct Answer: B
Rationale: Bright red urine with many clots post-TURP indicates significant bleeding or clot obstruction, requiring immediate reporting to prevent complications. The other findings are less urgent.
Question 3 of 5
The nurse is caring for the client with a mastectomy. Which action would be contraindicated?
Correct Answer: A
Rationale: Taking blood pressure on the mastectomy side is contraindicated due to the risk of lymphedema from compromised lymphatic drainage post-surgery. Elevating the arm, positioning on the unaffected side, and fingersticks on the unaffected side are safe.
Question 4 of 5
A client is admitted to the unit two hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
Correct Answer: B
Rationale: Facial burns can cause swelling and laryngeal edema compromising the airway within hours. This is the most immediate life-threatening concern. Hypovolemia hypernatremia and hyperkalemia are also risks but are less urgent in the first two hours.
Question 5 of 5
A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy. Which of the following strategies should be most effective in encouraging the child to eat?
Correct Answer: D
Rationale: Small servings appear more achievable to the child, and the inclusion of favorite foods can add a sense of security, encouraging eating.