NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 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 2 of 5
The nurse is caring for a client with a history of a mastectomy. The client complains of arm swelling. The nurse should:
Correct Answer: B
Rationale: Arm swelling post-mastectomy suggests lymphedema, and elevating the arm reduces fluid accumulation. Warm compresses and massage may worsen swelling, and notification is secondary.
Question 3 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 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
A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital's psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifies that the best approach to this problem is to:
Correct Answer: C
Rationale:
To interfere with the ritual will increase anxiety. Arranging the schedule to allow completion of the ritual before essential activities like breakfast accommodates the client's needs while addressing the issue.