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
An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
Correct Answer: B
Rationale: Bright red urine with many clots post-TURP indicates significant bleeding or clot obstruction, requiring immediate reporting to prevent complications. The other findings are less urgent.
Question 3 of 5
A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:
Correct Answer: B
Rationale: Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. FHR (movement) observed DISTINCT on ultrasound is a positive diagnosis of pregnancy. Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.
Question 4 of 5
A client with a history of gastric ulcer is admitted with complaints of epigastric pain. The nurse should give priority to:
Correct Answer: B
Rationale: Epigastric pain in gastric ulcer may indicate bleeding, so monitoring for bleeding is the priority to prevent complications like anemia.
Question 5 of 5
The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be:
Correct Answer: A
Rationale: The most serious adverse reactions of MAO inhibitors involve blood pressure and ingestion of tyramine-containing foods, which may provoke a hypertensive crisis. MAO inhibitors cause adverse reactions affecting the central nervous system and serious adverse reactions involving blood pressure. MAO inhibitors affect neurotransmitters and may produce hypotensive reactions, but hypertensive crisis is the primary concern with tyramine. Gastrointestinal side effects may occur, but they are not the most serious adverse reactions.