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 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as 'a cramp in my leg.' An appropriate nursing action is to:
Correct Answer: B
Rationale: Calf pain with dorsiflexion of the foot (Homans' sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. A pillow behind the knee can be constricting and further impair blood flow.
Question 3 of 5
The nurse is caring for a client with pancreatitis. Which of the following IV medications would the nurse expect the physician to prescribe for control of pain in this client?
Correct Answer: D
Rationale: Meperidine is the drug of choice for clients with pancreatitis. It will not cause spasms at the sphincter of Oddi, which can lead to increased pancreatic pain.
Question 4 of 5
The best indicator of peripheral edema is determined by:
Correct Answer: D
Rationale: Checking for pitting (indentation after pressing the skin) is the most direct and reliable indicator of peripheral edema. While weight extremity measurement and intake/output are relevant pitting specifically confirms edema.
Question 5 of 5
The nurse is caring for the client with a mastectomy. Which action would be contraindicated?
Correct Answer: A
Rationale: Taking blood pressure on the mastectomy side is contraindicated due to the risk of lymphedema from compromised lymphatic drainage post-surgery. Elevating the arm, positioning on the unaffected side, and fingersticks on the unaffected side are safe.