NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 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.
Question 2 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 3 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 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
In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle?
Correct Answer: C
Rationale: Progesterone from the corpus luteum causes endometrial swelling in the secretory phase, preparing for potential implantation.