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
The nurse is caring for a client with myasthenia gravis who is having trouble breathing. The nurse would encourage which of the following positions for maximal lung expansion?
Correct Answer: D
Rationale: Sitting or high Fowler’s position maximizes lung expansion by reducing diaphragm pressure in myasthenia gravis. Supine (
A), side-lying (
B), and prone (
C) positions restrict breathing.
Question 3 of 5
When performing Leopold maneuvers on a client at 32 weeks gestation, the nurse would expect to find:
Correct Answer: D
Rationale: At 32 weeks gestation, the fetus is active, and Leopold maneuvers typically detect strong, active fetal movement as the fetus grows and develops.
Question 4 of 5
The nurse is teaching a client with Parkinson's disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to:
Correct Answer: A
Rationale: Lying prone without a pillow helps counteract the forward flexion posture common in Parkinson's disease, reducing spinal curvature. The other positions do not effectively prevent flexion.
Question 5 of 5
A mother came to the pediatric clinic with her 17-month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training?
Correct Answer: B
Rationale: Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement. A child-sized toilet seat or training potty gives a child a feeling of security. She should use words that are age appropriate for the child. Children should be praised for cooperative behavior and/or successful evacuation.