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
A client with metastatic cancer of the lung has just been told the prognosis by the oncologist. The nurse hears the client state, "I don't believe the doctor; I think he has me confused with another patient."
Correct Answer: A
Rationale: The client's statement reflects denial, the first stage of Kubler-Ross' model, where patients refuse to accept a terminal prognosis. Anger (
B), depression (
C), and bargaining (
D) involve different emotional responses.
Question 3 of 5
A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:
Correct Answer: A
Rationale: At about 30-32 weeks' gestation, the amounts of the surfactants, lecithin, and sphingomyelin become equal. As the fetal lungs mature, the concentration of lecithin begins to exceed that of sphingomyelin. At 35 weeks, the L/S ratio is 2:1. Respiratory distress syndrome is unlikely if birth occurs at this time.
Question 4 of 5
A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks' gestation, all of the following observations are made. Which would require intervention?
Correct Answer: C
Rationale: This is not an excessive weight gain indicative of fluid retention. The blood pressure is within normal range. Showering should not cause shortness of breath. This could be a sign of cardiac decompensation. Dependent ankle edema is normal late in the day among pregnant women. Progressive edema would be a dangerous development.
Question 5 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.