NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?
Correct Answer: D
Rationale: Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. The decreased intake occurs due to fatigue from the altered cardiac output. Fatigue occurs due to the decreased cardiac output. The ineffective action of the myocardium leads to inadequate O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development.
Question 2 of 5
Which of the following age-related changes affect the vision of the elderly client?
Correct Answer: B, C, E
Rationale: Age-related vision changes include decreased lens elasticity (
B), lens discoloration (
C), and enophthalmos (E). Pupil dilation decreases (
A), and eye mobility is unaffected (
D).
Question 3 of 5
A female client at 36 weeks' gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate:
Correct Answer: D
Rationale: Placental maturity is assessed by a biophysical profile. L/S ratio and presence of phosphatidylglycerol are not used to determine fetal asphyxia. A biophysical profile score of 6 may indicate this condition. Cord compression is not reflected by the L/S ratio or presence of phosphatidylglycerol. Variable decelerations observed through electronic fetal monitoring could reflect umbilical cord compression. An L/S ratio >2 and the presence of phosphatidylglycerol in amniotic fluid indicate fetal lung maturity.
Question 4 of 5
The nurse notes that a post-operative client's respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for:
Correct Answer: D
Rationale: Narcan reverses opioid-induced respiratory depression but can precipitate withdrawal, causing sudden pain in opioid-dependent clients. Pupillary changes, vomiting, and wheezing are less immediate concerns.
Question 5 of 5
The nurse is caring for a client with a diagnosis of preeclampsia. Which intervention is most appropriate?
Correct Answer: D
Rationale: Magnesium sulfate prevents seizures blood pressure monitoring tracks hypertension and antihypertensives (e.g. hydralazine) manage severe hypertension in preeclampsia. All interventions are appropriate.