NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A client is diagnosed with organic brain disorder. The nursing care should include:
Correct Answer: A
Rationale: An organized, safe environment minimizes confusion and ensures safety for clients with organic brain disorders.
Question 2 of 5
The nurse is assessing a six-year-old following a tonsillectomy. Which one of the following signs is an early indication of hemorrhage?
Correct Answer: A
Rationale: Drooling of bright red secretions indicates active bleeding post-tonsillectomy, an early sign of hemorrhage requiring immediate attention.
Question 3 of 5
A client with severe anemia is to receive a unit of packed red blood cells. In the event of a transfusion reaction, the first action by the nurse should be to:
Correct Answer: B
Rationale: Stopping the transfusion and maintaining an IV of normal saline is the first action to prevent further reaction and stabilize the client.
Question 4 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 5 of 5
In assessing a person after experiencing spousal abuse, which need has the highest priority?
Correct Answer: C
Rationale: Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. The spouse may be self-medicating herself with alcohol or drugs to escape an awful situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.