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 nurse is caring for the client with a mastectomy. Which action would be contraindicated?
Correct Answer: A
Rationale: Taking blood pressure on the mastectomy side is contraindicated due to the risk of lymphedema from compromised lymphatic drainage post-surgery. Elevating the arm, positioning on the unaffected side, and fingersticks on the unaffected side are safe.
Question 3 of 5
The physician has ordered an injection of RhoGAM (Rho[D] immune globulin) for the postpartum client whose blood type is A negative and whose baby is O positive. To provide postpartum prophylaxis,RhoGAM should be administered:
Correct Answer: A
Rationale: RhoGAM prevents Rh sensitization in Rh-negative mothers by neutralizing fetal Rh-positive blood cells. It must be administered within 72 hours of delivery for effective prophylaxis.
Question 4 of 5
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for which one of the following side effects:
Correct Answer: C
Rationale: Ritodrine is a sympathomimetic β2-adrenergic agonist that can cause vasodilation, leading to hypotension. The body compensates by increasing heart rate, resulting in tachycardia.
Question 5 of 5
The client is diagnosed with Bell’s palsy. Which intervention should the nurse implement to protect the client’s affected eye?
Correct Answer: A
Rationale: Bell’s palsy causes facial paralysis, impairing eye closure and risking corneal damage. An eye patch at night protects the eye from drying and injury. Corticosteroids reduce inflammation, blinking is encouraged, and antibiotics are not indicated.