NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as 'a cramp in my leg.' An appropriate nursing action is to:
Correct Answer: B
Rationale: Calf pain with dorsiflexion of the foot (Homans' sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. A pillow behind the knee can be constricting and further impair blood flow.
Question 2 of 5
A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect. Based on his developmental stage, the nurse:
Correct Answer: B
Rationale: A toddler is not capable of conceptualizing about the inside of his body and is concerned about body intactness; therefore, diagrams would not be useful. Also, the previous evening is too far from the procedure for the toddler to remember the instructions. A simple explanation the morning of the procedure is the best developmental strategy to use, because it focuses on the toddler's need for parental support, body intactness, and short attention span. A relationship between the nurse and the child needs to develop. Also, misinformation may be given to the child if the parents explain the procedure to the child. The parents are the child's support system and need to be there to strengthen the child.
Question 3 of 5
The nurse is caring for a client with a history of asthma. Which medication should the nurse anticipate being ordered for an acute asthma attack?
Correct Answer: A
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma attacks, providing rapid bronchodilation. Prednisone is for long-term control, theophylline is less commonly used, and montelukast is for maintenance therapy.
Question 4 of 5
Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
Correct Answer: D
Rationale: Acticoat dressings require moistening with normal saline to activate the silver ions for antimicrobial action and to maintain a moist healing environment.
Question 5 of 5
The physician has prescribed Coumadin (sodium warfarin) for a client having transient ischemic attacks. Which laboratory test measures the therapeutic level of Coumadin?
Correct Answer: A
Rationale: Prothrombin time (PT/INR) measures Coumadin's anticoagulant effect by assessing clotting time. PTT monitors heparin, and clot retraction or bleeding time are unrelated.