NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
Correct Answer: C
Rationale: Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. Breast-feeding every 1½-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottle-feeding mother. Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.
Question 2 of 5
A mother came to the pediatric clinic with her 17-month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training?
Correct Answer: B
Rationale: Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement. A child-sized toilet seat or training potty gives a child a feeling of security. She should use words that are age appropriate for the child. Children should be praised for cooperative behavior and/or successful evacuation.
Question 3 of 5
The nurse is teaching a client with Parkinson's disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to:
Correct Answer: A
Rationale: Lying prone without a pillow helps counteract the forward flexion posture common in Parkinson's disease, reducing spinal curvature. The other positions do not effectively prevent flexion.
Question 4 of 5
A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:
Correct Answer: A
Rationale: Guiding the fetus's expulsion during a precipitous delivery minimizes injury and perineal trauma.
Question 5 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.