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 preparing to administer a dose of morphine sulfate IV to a client for pain. Which assessment is most important before administration?
Correct Answer: A
Rationale: Morphine, an opioid, can cause respiratory depression. Assessing the respiratory rate is critical before administration to ensure it is above 12 breaths per minute, preventing overdose risk. Other vital signs are monitored but are less critical.
Question 3 of 5
The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:
Correct Answer: C
Rationale: The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. Cerebrospinal fluid is positive for sugar; mucus is not. Turning her to her side will have no effect on her 'runny nose.' It is necessary to gather further assessment data.
Question 4 of 5
The nurse is caring for a client with a history of a diabetic foot ulcer. The nurse should:
Correct Answer: B
Rationale: Elevating the foot reduces swelling and promotes healing in a diabetic foot ulcer. Heating pads, soaking, and massage increase infection risk or impair circulation.
Question 5 of 5
The nurse working in a clinic is reviewing the chart of a client with a probable anemia. Which would most likely indicate a deficiency in Vitamin B12?
Correct Answer: B, C, F
Rationale: Vitamin B12 deficiency causes megaloblastic anemia with splenomegaly (
B), nausea (
C), and anorexia (F). Night cramps (
A), cheilosis (
D), and petechiae (E) are more associated with other deficiencies (e.g., iron, folate).