NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?
Correct Answer: A
Rationale: Clients with respiratory diseases are generally mouth breathers. Cleaning the oral cavity may improve the client's appetite, increase her feelings of well-being, and remove the taste and odor of sputum. Milk causes thick sputum; therefore, milk products would not be beneficial for this client. Exercise prior to a meal would require increased O2 consumption and most likely would decrease the client's ability to eat. Clients with respiratory diseases need increased fluid to liquefy secretions.
Question 2 of 5
The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be:
Correct Answer: A
Rationale: The most serious adverse reactions of MAO inhibitors involve blood pressure and ingestion of tyramine-containing foods, which may provoke a hypertensive crisis. MAO inhibitors cause adverse reactions affecting the central nervous system and serious adverse reactions involving blood pressure. MAO inhibitors affect neurotransmitters and may produce hypotensive reactions, but hypertensive crisis is the primary concern with tyramine. Gastrointestinal side effects may occur, but they are not the most serious adverse reactions.
Question 3 of 5
A client with cancer received platelet infusions 24 hours ago.
Correct Answer: D
Rationale: Platelet infusions aim to improve clotting. Decreased oozing from an IV site (
D) indicates effective platelet function. Hemoglobin (
A), temperature (
B), and WBC (
C) are not directly affected.
Question 4 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 5 of 5
The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:
Correct Answer: C
Rationale: The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. Cerebrospinal fluid is positive for sugar; mucus is not. Turning her to her side will have no effect on her 'runny nose.' It is necessary to gather further assessment data.