NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 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 2 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 3 of 5
A nurse is assisting the physician with chest tube removal. Which client instruction is appropriate during removal of the tube?
Correct Answer: A
Rationale: Taking a deep breath or humming (Valsalva maneuver) during chest tube removal increases intrathoracic pressure, preventing air entry. Holding breath for two minutes (
B) is excessive, exhaling (
C) risks pneumothorax, and deep breathing (
D) is unsafe.
Question 4 of 5
A client is admitted to the emergency room with partial-thickness burns to his right arm and full-thickness burns to his trunk. According to the Rule of Nines, the nurse calculates that the total body surface area (TBSA) involved is:
Correct Answer: B
Rationale: Per the Rule of Nines, the right arm is 9% and the trunk (anterior and posterior) is 36%. Partial- and full-thickness burns to the right arm and trunk approximate 35% TBSA.
Question 5 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.