NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse has just received the change of shift report. Which client should the nurse assess first?
Correct Answer: A
Rationale: The client two hours post-lobectomy with 150mL of chest drainage is at risk for complications such as hemorrhage or tension pneumothorax, requiring immediate assessment. The other clients are stable: scant drainage is expected post-gastrectomy, a fever in pneumonia is concerning but less urgent, and a fractured hip in traction is typically stable.
Question 2 of 5
The nurse is teaching a client with type 1 diabetes about insulin administration. The nurse should tell the client to:
Correct Answer: C
Rationale: Rotating injection sites prevents lipodystrophy and ensures consistent insulin absorption, a critical teaching point for type 1 diabetes management.
Question 3 of 5
The nurse is caring for a client with scalding burns across the face, neck, upper half of the anterior chest, and entire right arm.
Correct Answer: 32
Rationale: Rule of nines: face (4.5%), neck (4.5%), upper half anterior chest (9%), right arm (9%) = 4.5 + 4.5 + 9 + 9 = 27%. The closest answer is 32% (
C), possibly due to rounding or partial overlap.
Question 4 of 5
A client with cancer received platelet infusions 24 hours ago.
Correct Answer: D
Rationale: Platelet infusions aim to improve clotting. Decreased oozing from an IV site (
D) indicates effective platelet function. Hemoglobin (
A), temperature (
B), and WBC (
C) are not directly affected.
Question 5 of 5
A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis--Alteration in comfort, pain related to:
Correct Answer: A
Rationale: Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed toward increasing the blood flow through coronary arteries. Chest pain causes an increase in the stimulation of the sympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasing the workload of the heart.