NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the child was placed under an oxygen mist tent. The nurse's frequent monitoring of the child's temperature frightened her parents. Which response by the nurse would be most appropriate?
Correct Answer: A
Rationale: The refrigerated cool mist tent creates a cool, moist environment. Monitoring the temperature of the child will ensure warmth and prevent chilling.
Question 2 of 5
A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis--Alteration in comfort, pain related to:
Correct Answer: A
Rationale: Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed toward increasing the blood flow through coronary arteries. Chest pain causes an increase in the stimulation of the sympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasing the workload of the heart.
Question 3 of 5
A client with a history of a burn injury is being discharged. The nurse should teach the client to:
Correct Answer: A
Rationale: Avoiding sun exposure protects healing burn skin from UV damage and hyperpigmentation. Harsh soaps, petroleum lotions, and tight clothing can irritate or delay healing.
Question 4 of 5
The physician has prescribed Cobex (cyanocobalamin) for a client following a gastric resection. Which lab result indicates that the medication is having its intended effect?
Correct Answer: B
Rationale: Cyanocobalamin (vitamin B12) treats pernicious anemia post-gastric resection by improving red blood cell production, reflected by a normal hemoglobin (Hgb) level of 14.2 g/dL.
Question 5 of 5
The nurse is caring for a client with a history of a mastectomy. The client complains of arm swelling. The nurse should:
Correct Answer: B
Rationale: Arm swelling post-mastectomy suggests lymphedema, and elevating the arm reduces fluid accumulation. Warm compresses and massage may worsen swelling, and notification is secondary.