NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?
Correct Answer: B
Rationale: These delusions are related to the belief that an individual has an incurable illness. These delusions are related to feelings of self-importance and uniqueness. These delusions are related to feelings of being conspired against. These delusions are related to denial of self-existence.
Question 2 of 5
Which ECG finding is most likely to be present in the client with a potassium of 6.0 mEq/L?
Correct Answer: C
Rationale: Hyperkalemia (potassium 6.0 mEq/L) typically causes peaked T waves on an ECG due to altered cardiac repolarization. Depressed S-T segments and U waves are more associated with hypokalemia and T/U wave fusion is less common.
Question 3 of 5
The nurse is caring for a client with a diagnosis of preeclampsia. Which vital sign change is most concerning?
Correct Answer: A
Rationale: A blood pressure of 160/110 in preeclampsia indicates severe hypertension increasing the risk of stroke or eclampsia and requires immediate intervention. The other vital signs are within normal limits.
Question 4 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 5 of 5
The nurse is caring for a client with a diagnosis of ectopic pregnancy. Which diagnostic test is most likely to be ordered?
Correct Answer: C
Rationale: Ultrasound confirms the location of the pregnancy (e.g. outside the uterus) and serial serum hCG levels help diagnose ectopic pregnancy by showing abnormal doubling patterns. Both tests are commonly ordered.