NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A client with a history of a C4 spinal cord injury is being prepared for discharge. Before discharge, the nurse should make sure that the client can:
Correct Answer: C
Rationale: A C4 spinal cord injury causes tetraplegia, limiting upper extremity function. Transferring to a wheelchair is critical for mobility and discharge readiness, often requiring adaptive techniques.
Question 2 of 5
The nurse is caring for the client with a mastectomy. Which action would be contraindicated?
Correct Answer: A
Rationale: Taking blood pressure on the mastectomy side is contraindicated due to the risk of lymphedema from compromised lymphatic drainage post-surgery. Elevating the arm, positioning on the unaffected side, and fingersticks on the unaffected side are safe.
Question 3 of 5
At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?
Correct Answer: B
Rationale: Bradycardia of 50-70 bpm may be considered normal postpartally because the heart compensates for the decreased resistance in the pelvis. The uterus is displaced from the midline by a full bladder. This condition could lead to a boggy uterus and increased risk of postpartal hemorrhage; therefore, the bladder should be kept empty. Re-establishment of normal bowel function is delayed into the first postpartum week. A postpartum woman's oral temperature may go as high as 100.4°F within 24 hours of delivery resulting from muscular exertion, dehydration, and hormonal changes.
Question 4 of 5
A client with a history of asthma is experiencing an acute exacerbation. Which medication would the nurse expect to administer first?
Correct Answer: A
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma exacerbation, rapidly relieving bronchospasm. Prednisone (
B), Ipratropium (
C), and Montelukast (
D) are adjunctive or long-term therapies.
Question 5 of 5
A nurse is assisting the physician with chest tube removal. Which client instruction is appropriate during removal of the tube?
Correct Answer: A
Rationale: Taking a deep breath or humming (Valsalva maneuver) during chest tube removal increases intrathoracic pressure, preventing air entry. Holding breath for two minutes (
B) is excessive, exhaling (
C) risks pneumothorax, and deep breathing (
D) is unsafe.