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
A client is admitted with kidney disease. Which type of intravenous fluid is likely to be ordered for this client?
Correct Answer: B
Rationale: Isotonic fluids (e.g. 0.9% normal saline) are typically used in kidney disease to maintain fluid balance without overloading or stressing impaired kidneys. Hypertonic or hypotonic fluids may disrupt electrolyte balance and colloids are used for specific indications like shock.
Question 3 of 5
A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?
Correct Answer: A
Rationale: Clients with respiratory diseases are generally mouth breathers. Cleaning the oral cavity may improve the client's appetite, increase her feelings of well-being, and remove the taste and odor of sputum. Milk causes thick sputum; therefore, milk products would not be beneficial for this client. Exercise prior to a meal would require increased O2 consumption and most likely would decrease the client's ability to eat. Clients with respiratory diseases need increased fluid to liquefy secretions.
Question 4 of 5
A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:
Correct Answer: B
Rationale: Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. FHR (movement) observed DISTINCT on ultrasound is a positive diagnosis of pregnancy. Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.
Question 5 of 5
Which tasks should not be delegated to the unlicensed assistive personnel?
Correct Answer: C
Rationale: Unlicensed assistive personnel (UAP) can perform basic care tasks like bathing (
A), perineal care (E), and assisting with feeding under supervision (
B). Basic life support (
D) may be within their scope if trained. However, administering parenteral medications (
C) requires assessment and judgment, which is beyond UAP scope and reserved for licensed nurses.