NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:
Correct Answer: C
Rationale: The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. Cerebrospinal fluid is positive for sugar; mucus is not. Turning her to her side will have no effect on her 'runny nose.' It is necessary to gather further assessment data.
Question 2 of 5
A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks' gestation, all of the following observations are made. Which would require intervention?
Correct Answer: C
Rationale: This is not an excessive weight gain indicative of fluid retention. The blood pressure is within normal range. Showering should not cause shortness of breath. This could be a sign of cardiac decompensation. Dependent ankle edema is normal late in the day among pregnant women. Progressive edema would be a dangerous development.
Question 3 of 5
The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include:
Correct Answer: B
Rationale: Eye pain is a symptom of hemorrhage, and itching is associated with infection. The other options include symptoms not typically related to eye infection or hemorrhage.
Question 4 of 5
The nurse instructs a client on the difference between true labor and false labor. The nurse explains, 'In true labor:
Correct Answer: B
Rationale: In true labor, uterine contractions strengthen and become more regular with activity like walking, facilitating cervical dilation and fetal descent.
Question 5 of 5
A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:
Correct Answer: A
Rationale: The client with hypothyroidism is the most suitable roommate, as this condition is non-infectious and poses no risk to the immunocompromised vascular surgery client. Gastroenteritis and bacterial pneumonia are infectious, and diabetic ulcers may involve infection, increasing cross-contamination risk.