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
Which tasks should not be delegated to the unlicensed assistive personnel?
Correct Answer: C
Rationale: Unlicensed assistive personnel (UAP) can perform basic care tasks like bathing (
A), perineal care (E), and assisting with feeding under supervision (
B). Basic life support (
D) may be within their scope if trained. However, administering parenteral medications (
C) requires assessment and judgment, which is beyond UAP scope and reserved for licensed nurses.
Question 3 of 5
In assessing a person after experiencing spousal abuse, which need has the highest priority?
Correct Answer: C
Rationale: Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. The spouse may be self-medicating herself with alcohol or drugs to escape an awful situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.
Question 4 of 5
When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:
Correct Answer: D
Rationale: Tube feedings should be withheld and physician notified for residual volumes of 50-100 mL.
Question 5 of 5
A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include:
Correct Answer: A
Rationale: Providing a more structured, supportive environment addresses safety and comfort needs, thereby helping the anorexic client develop more internal control. Medications (commonly antidepressants) are frequently ordered for the体系, but lithium (used primarily with bipolar disorder) is not commonly used to treat the anorexic client. Requiring and/or demanding that the anorexic client 'eat more' at mealtimes increases the client's feelings of powerlessness.