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
The client is diagnosed with a retinal detachment. Which symptom is most likely reported by the client?
Correct Answer: A
Rationale: Retinal detachment typically causes sudden vision loss, often described as a curtain over the visual field. Pain, redness, and double vision are less common.
Question 3 of 5
During an intake assessment, the nurse asks the client if he has an advanced directive. The reason for asking the client this question is:
Correct Answer: B
Rationale: An advanced directive clarifies a client’s wishes for medical care, reducing confusion and conflict among family or healthcare providers, especially in critical situations. It does not address funeral plans, allow staff to make decisions, or permit euthanasia.
Question 4 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.
Question 5 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.