NCLEX-PN
ATI NCLEX-PN Practice Questions Questions
Extract:
Question 1 of 5
The client with a closed head injury is admitted to the neurointensive care department following a motor-vehicle accident. Which goal is an appropriate short-term goal for the client?
Correct Answer: C
Rationale: Maintaining ICP <15 mm Hg is a critical short-term goal in head injury to prevent brain damage, per neuro ICU standards.
Question 2 of 5
The client with severe itching from an insect bite calls the clinic and asks the nurse, 'What do I need to do for the itching?' Which intervention should the nurse implement for the client problem of alteration in comfort?
Correct Answer: B
Rationale: Benadryl gel (diphenhydramine) relieves itching effectively, applied PRN. Tylenol/aspirin don’t target itching, hot water may worsen it, and hydrocortisone every 2 hours is excessive.
Question 3 of 5
The male client is wearing a silver amulet to protect from evil spirits. Which action should the nurse take when sending the client to surgery?
Correct Answer: D
Rationale: Taping the amulet respects the client’s spiritual beliefs while ensuring safety in the OR, per patient-centered care. Removing, sending home, or questioning beliefs is less sensitive.
Question 4 of 5
The female client with a cold is prescribed warfarin (Coumadin), an anticoagulant, for chronic atrial fibrillation. The client calls the clinic and tells the nurse she is bleeding and bruising more than normal. Which information indicates a need for further teaching?
Correct Answer: A
Rationale: Echinacea may interact with warfarin, increasing bleeding risk, indicating a need for teaching about herb-drug interactions. Monthly INR, acetaminophen (safe with warfarin), and label reading are appropriate.
Question 5 of 5
Which assessment data indicate the client has developed a deep vein thrombosis (DVT) in the left leg?
Correct Answer: B
Rationale: Increased calf circumference suggests DVT due to swelling from clot-related obstruction.