NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:
Correct Answer: A
Rationale: At about 30-32 weeks' gestation, the amounts of the surfactants, lecithin, and sphingomyelin become equal. As the fetal lungs mature, the concentration of lecithin begins to exceed that of sphingomyelin. At 35 weeks, the L/S ratio is 2:1. Respiratory distress syndrome is unlikely if birth occurs at this time.
Question 2 of 5
The client is prescribed ciprofloxacin (Cipro) for a urinary tract infection. Which instruction should the nurse include?
Correct Answer: B
Rationale: Ciprofloxacin can cause photosensitivity, so avoiding sun exposure prevents skin reactions. Dairy products reduce absorption, and the full course must be completed, regardless of symptoms.
Question 3 of 5
The nurse is caring for a client with a history of a diabetic foot ulcer. The nurse should:
Correct Answer: B
Rationale: Elevating the foot reduces swelling and promotes healing in a diabetic foot ulcer. Heating pads, soaking, and massage increase infection risk or impair circulation.
Question 4 of 5
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
Correct Answer: B
Rationale: Hypersomnolence (drowsiness) is an expected side effect of magnesium sulfate used for preeclampsia due to its central nervous system depressant effects. Absence of reflexes or decreased respiratory rate would indicate toxicity not an expected effect.
Question 5 of 5
A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:
Correct Answer: A
Rationale: Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and survival is likely.