NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A mother came to the pediatric clinic with her 17-month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training?
Correct Answer: B
Rationale: Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement. A child-sized toilet seat or training potty gives a child a feeling of security. She should use words that are age appropriate for the child. Children should be praised for cooperative behavior and/or successful evacuation.
Question 2 of 5
A female client at 36 weeks' gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate:
Correct Answer: D
Rationale: Placental maturity is assessed by a biophysical profile. L/S ratio and presence of phosphatidylglycerol are not used to determine fetal asphyxia. A biophysical profile score of 6 may indicate this condition. Cord compression is not reflected by the L/S ratio or presence of phosphatidylglycerol. Variable decelerations observed through electronic fetal monitoring could reflect umbilical cord compression. An L/S ratio >2 and the presence of phosphatidylglycerol in amniotic fluid indicate fetal lung maturity.
Question 3 of 5
A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:
Correct Answer: A
Rationale: Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and survival is likely.
Question 4 of 5
A client hospitalized for treatment of congestive heart failure is to be discharged with a prescription for Digitek (digoxin) 0.25 mg daily. Which of the following statements indicates that the client needs further teaching?
Correct Answer: B
Rationale: Taking digoxin with an antacid can decrease its absorption, reducing effectiveness, so this statement indicates a need for further teaching.
Question 5 of 5
The nurse is caring for a client with a diagnosis of postpartum hemorrhage. Which medication is most likely to be ordered?
Correct Answer: B
Rationale: Methylergonovine (Methergine) is an oxytocic used to treat postpartum hemorrhage by promoting uterine contractions to control bleeding. Magnesium sulfate is for preeclampsia terbutaline is a tocolytic and betamethasone is for fetal lung maturity.