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
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 notes that a post-operative client's respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for:
Correct Answer: D
Rationale: Narcan reverses opioid-induced respiratory depression but can precipitate withdrawal, causing sudden pain in opioid-dependent clients. Pupillary changes, vomiting, and wheezing are less immediate concerns.
Question 4 of 5
The nurse is caring for an eight-year-old following a routine tonsillectomy. Which finding should be reported immediately?
Correct Answer: D
Rationale: Respiratory stridor post-tonsillectomy suggests airway obstruction, a life-threatening complication requiring immediate reporting. The other findings are normal or less urgent.
Question 5 of 5
The nurse is caring for a client with a diagnosis of preeclampsia. Which vital sign change is most concerning?
Correct Answer: A
Rationale: A blood pressure of 160/110 in preeclampsia indicates severe hypertension increasing the risk of stroke or eclampsia and requires immediate intervention. The other vital signs are within normal limits.