NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:
Correct Answer: B
Rationale: While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence.
Question 2 of 5
In assessing a person after experiencing spousal abuse, which need has the highest priority?
Correct Answer: C
Rationale: Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. The spouse may be self-medicating herself with alcohol or drugs to escape an awful situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.
Question 3 of 5
The nurse is preparing to administer a dose of morphine sulfate IV to a client for pain. Which assessment is most important before administration?
Correct Answer: A
Rationale: Morphine, an opioid, can cause respiratory depression. Assessing the respiratory rate is critical before administration to ensure it is above 12 breaths per minute, preventing overdose risk. Other vital signs are monitored but are less critical.
Question 4 of 5
The nurse is caring for a client with a history of a seizure disorder who is receiving Lamotrigine (Lamictal). The nurse should monitor the client for:
Correct Answer: A
Rationale: Lamotrigine can cause a serious rash, including Stevens-Johnson syndrome, requiring immediate monitoring and reporting. Hypotension, hyperglycemia, and weight gain are not primary concerns.
Question 5 of 5
The nurse is caring for a client with a diagnosis of incompetent cervix. Which intervention is most appropriate?
Correct Answer: B
Rationale: Incompetent cervix where the cervix dilates prematurely is treated with cerclage (a stitch to reinforce the cervix).
Tocolytics may be adjunctive fetal distress monitoring is secondary and antibiotics are not routinely indicated.