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
A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:
Correct Answer: A
Rationale: The client with hypothyroidism is the most suitable roommate, as this condition is non-infectious and poses no risk to the immunocompromised vascular surgery client. Gastroenteritis and bacterial pneumonia are infectious, and diabetic ulcers may involve infection, increasing cross-contamination risk.
Question 3 of 5
A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?
Correct Answer: D
Rationale: Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. The decreased intake occurs due to fatigue from the altered cardiac output. Fatigue occurs due to the decreased cardiac output. The ineffective action of the myocardium leads to inadequate O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development.
Question 4 of 5
A client is admitted to the emergency room with partial-thickness burns to his right arm and full-thickness burns to his trunk. According to the Rule of Nines, the nurse calculates that the total body surface area (TBSA) involved is:
Correct Answer: B
Rationale: Per the Rule of Nines, the right arm is 9% and the trunk (anterior and posterior) is 36%. Partial- and full-thickness burns to the right arm and trunk approximate 35% TBSA.
Question 5 of 5
A client is admitted with kidney disease. Which type of intravenous fluid is likely to be ordered for this client?
Correct Answer: B
Rationale: Isotonic fluids (e.g. 0.9% normal saline) are typically used in kidney disease to maintain fluid balance without overloading or stressing impaired kidneys. Hypertonic or hypotonic fluids may disrupt electrolyte balance and colloids are used for specific indications like shock.