NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 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 2 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 3 of 5
The nurse is teaching a client with a history of hypertension about lifestyle modifications. The nurse should tell the client to:
Correct Answer: A
Rationale: Reducing stress lowers blood pressure in hypertension, improving cardiovascular health.
Question 4 of 5
The client is prescribed ciprofloxacin (Cipro) for a urinary tract infection. Which instruction should the nurse include?
Correct Answer: B
Rationale: Ciprofloxacin can cause photosensitivity, so avoiding sun exposure prevents skin reactions. Dairy products reduce absorption, and the full course must be completed, regardless of symptoms.
Question 5 of 5
The best indicator of peripheral edema is determined by:
Correct Answer: D
Rationale: Checking for pitting (indentation after pressing the skin) is the most direct and reliable indicator of peripheral edema. While weight extremity measurement and intake/output are relevant pitting specifically confirms edema.