NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is assessing a six-year-old following a tonsillectomy. Which one of the following signs is an early indication of hemorrhage?
Correct Answer: A
Rationale: Drooling of bright red secretions indicates active bleeding post-tonsillectomy, an early sign of hemorrhage requiring immediate attention.
Question 2 of 5
A client with a history of a burn injury is being discharged. The nurse should teach the client to:
Correct Answer: A
Rationale: Avoiding sun exposure protects healing burn skin from UV damage and hyperpigmentation. Harsh soaps, petroleum lotions, and tight clothing can irritate or delay healing.
Question 3 of 5
A female client at 36 weeks' gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate:
Correct Answer: D
Rationale: Placental maturity is assessed by a biophysical profile. L/S ratio and presence of phosphatidylglycerol are not used to determine fetal asphyxia. A biophysical profile score of 6 may indicate this condition. Cord compression is not reflected by the L/S ratio or presence of phosphatidylglycerol. Variable decelerations observed through electronic fetal monitoring could reflect umbilical cord compression. An L/S ratio >2 and the presence of phosphatidylglycerol in amniotic fluid indicate fetal lung maturity.
Question 4 of 5
Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:
Correct Answer: A
Rationale: Succinylcholine chloride relaxes muscles and decreases the intensity of the seizure during electroconvulsive therapy.
Question 5 of 5
A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect. Based on his developmental stage, the nurse:
Correct Answer: B
Rationale: A toddler is not capable of conceptualizing about the inside of his body and is concerned about body intactness; therefore, diagrams would not be useful. Also, the previous evening is too far from the procedure for the toddler to remember the instructions. A simple explanation the morning of the procedure is the best developmental strategy to use, because it focuses on the toddler's need for parental support, body intactness, and short attention span. A relationship between the nurse and the child needs to develop. Also, misinformation may be given to the child if the parents explain the procedure to the child. The parents are the child's support system and need to be there to strengthen the child.