NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?
Correct Answer: B
Rationale: Bradycardia of 50-70 bpm may be considered normal postpartally because the heart compensates for the decreased resistance in the pelvis. The uterus is displaced from the midline by a full bladder. This condition could lead to a boggy uterus and increased risk of postpartal hemorrhage; therefore, the bladder should be kept empty. Re-establishment of normal bowel function is delayed into the first postpartum week. A postpartum woman's oral temperature may go as high as 100.4°F within 24 hours of delivery resulting from muscular exertion, dehydration, and hormonal changes.
Question 2 of 5
Which of the following foods,if selected by the mother of a child with celiac disease would indicate her understanding of the dietary instructions?
Correct Answer: D
Rationale: Celiac disease requires a gluten-free diet. Rice cereal is gluten-free unlike whole-wheat toast pasta and rye bread which contain gluten and are contraindicated.
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
The nurse has just received the change of shift report. Which client should the nurse assess first?
Correct Answer: A
Rationale: The client two hours post-lobectomy with 150mL of chest drainage is at risk for complications such as hemorrhage or tension pneumothorax, requiring immediate assessment. The other clients are stable: scant drainage is expected post-gastrectomy, a fever in pneumonia is concerning but less urgent, and a fractured hip in traction is typically stable.
Question 5 of 5
Which action can be delegated to the licensed practical nurse?
Correct Answer: A, B, E
Rationale: LPNs can insert catheters (
A), perform tracheostomy care (
B), and change sterile dressings (E) within their scope. Initiating blood transfusions (
C) and irrigating PICC lines (
D) require RN-level assessment and monitoring.