NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:
Correct Answer: A
Rationale: Guiding the fetus's expulsion during a precipitous delivery minimizes injury and perineal trauma.
Question 2 of 5
The nurse working in a clinic is reviewing the chart of a client with a probable anemia. Which would most likely indicate a deficiency in Vitamin B12?
Correct Answer: B, C, F
Rationale: Vitamin B12 deficiency causes megaloblastic anemia with splenomegaly (
B), nausea (
C), and anorexia (F). Night cramps (
A), cheilosis (
D), and petechiae (E) are more associated with other deficiencies (e.g., iron, folate).
Question 3 of 5
On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
Correct Answer: C
Rationale: Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. Breast-feeding every 1½-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottle-feeding mother. Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.
Question 4 of 5
A client with a history of a fractured femur is in skeletal traction. The nurse should:
Correct Answer: B
Rationale: Cleaning pin sites with saline (or per protocol) prevents infection in skeletal traction. Turning is limited, lotion is unnecessary, and removing weights disrupts traction.
Question 5 of 5
The client is prescribed albuterol (Proventil) for asthma. Which side effect should the nurse monitor for?
Correct Answer: B
Rationale: Albuterol, a beta-agonist, stimulates the sympathetic nervous system, causing tremors as a common side effect. Tachycardia (not bradycardia), hypertension, and diarrhea are more likely than hypotension or constipation.