NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
Correct Answer: B
Rationale: Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. Increased cardiac output results as fluids shift back to the vascular compartment. Hypertension is the result of hypervolemia.
Question 2 of 5
The nurse is caring for a client with a history of breast cancer who is receiving Tamoxifen (Nolvadex). The nurse should monitor the client for:
Correct Answer: A
Rationale: Tamoxifen, an anti-estrogen, commonly causes hot flashes due to hormonal changes. Blood pressure, appetite, and hair loss are not primary side effects.
Question 3 of 5
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
Correct Answer: B
Rationale: Hypersomnolence (drowsiness) is an expected side effect of magnesium sulfate used for preeclampsia due to its central nervous system depressant effects. Absence of reflexes or decreased respiratory rate would indicate toxicity not an expected effect.
Question 4 of 5
A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?
Correct Answer: D
Rationale: The nurse should discourage the child from coughing, clearing the throat, or putting objects in his mouth. These may induce bleeding. Cool, clear liquids may be given when child is fully alert. Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to distinguish fresh or old blood from ingested liquid should the child vomit. Gargles and vigorous toothbrushing could initiate bleeding. Postoperative hemorrhage, though unusual, may occur. The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright red blood, continuous swallowing, and changes in vital signs.
Question 5 of 5
The nurse is assessing a six-year-old following a tonsillectomy. Which one of the following signs is an early indication of hemorrhage?
Correct Answer: A
Rationale: Drooling of bright red secretions indicates active bleeding post-tonsillectomy, an early sign of hemorrhage requiring immediate attention.