NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
During an intake assessment, the nurse asks the client if he has an advanced directive. The reason for asking the client this question is:
Correct Answer: B
Rationale: An advanced directive clarifies a client’s wishes for medical care, reducing confusion and conflict among family or healthcare providers, especially in critical situations. It does not address funeral plans, allow staff to make decisions, or permit euthanasia.
Question 2 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 3 of 5
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
Correct Answer: B
Rationale: Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. Increased cardiac output results as fluids shift back to the vascular compartment. Hypertension is the result of hypervolemia.
Question 4 of 5
A client with a history of a C4 spinal cord injury is being prepared for discharge. Before discharge, the nurse should make sure that the client can:
Correct Answer: C
Rationale: A C4 spinal cord injury causes tetraplegia, limiting upper extremity function. Transferring to a wheelchair is critical for mobility and discharge readiness, often requiring adaptive techniques.
Question 5 of 5
The nurse is caring for a client with a radium implant for the treatment of cervical cancer. While caring for the client with a radioactive implant, the nurse should:
Correct Answer: D
Rationale: Wearing a radiation badge monitors exposure during care of a client with a radium implant, ensuring safety. Prolonged time, standing at the bed's foot, or avoiding items is less practical.