NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:
Correct Answer: C
Rationale: This action is inappropriate. Coughing will not re-expand the lung and could result in further harm. This action is a medical procedure, not a nursing procedure. An occlusive dressing will prevent further air leak until the physician institutes further treatment. The decision to reinsert the tube is a medical decision, not a nursing one.
Question 2 of 5
The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include:
Correct Answer: B
Rationale: Eye pain is a symptom of hemorrhage, and itching is associated with infection. The other options include symptoms not typically related to eye infection or hemorrhage.
Question 3 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.
Question 4 of 5
A client with a history of a liver transplant is receiving Tacrolimus (Prograf). The nurse should monitor the client for:
Correct Answer: A
Rationale: Tacrolimus is nephrotoxic, requiring monitoring of renal function (e.g., creatinine). Hyperglycemia is possible but less critical, and hypotension/hair loss are not primary concerns.
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.