NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
Correct Answer: D
Rationale: Acticoat dressings require moistening with normal saline to activate the silver ions for antimicrobial action and to maintain a moist healing environment.
Question 2 of 5
The nurse notes that a post-operative client's respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for:
Correct Answer: D
Rationale: Narcan reverses opioid-induced respiratory depression but can precipitate withdrawal, causing sudden pain in opioid-dependent clients. Pupillary changes, vomiting, and wheezing are less immediate concerns.
Question 3 of 5
A two-year-old is being evaluated for hearing loss. Which finding in the child's history is likely to be a significant factor?
Correct Answer: D
Rationale: Meningitis treated with garamycin (gentamicin) is a significant risk factor for hearing loss as gentamicin is ototoxic and meningitis can damage auditory nerves. The other factors are less directly associated with hearing impairment.
Question 4 of 5
A client with metastatic cancer of the lung has just been told the prognosis by the oncologist. The nurse hears the client state, "I don't believe the doctor; I think he has me confused with another patient."
Correct Answer: A
Rationale: The client's statement reflects denial, the first stage of Kubler-Ross' model, where patients refuse to accept a terminal prognosis. Anger (
B), depression (
C), and bargaining (
D) involve different emotional responses.
Question 5 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.