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
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 3 of 5
Which ECG finding is most likely to be present in the client with a potassium of 6.0 mEq/L?
Correct Answer: C
Rationale: Hyperkalemia (potassium 6.0 mEq/L) typically causes peaked T waves on an ECG due to altered cardiac repolarization. Depressed S-T segments and U waves are more associated with hypokalemia and T/U wave fusion is less common.
Question 4 of 5
The nurse is caring for a client with a diagnosis of preeclampsia. Which vital sign change is most concerning?
Correct Answer: A
Rationale: A blood pressure of 160/110 in preeclampsia indicates severe hypertension increasing the risk of stroke or eclampsia and requires immediate intervention. The other vital signs are within normal limits.
Question 5 of 5
A client with a history of endometriosis is admitted with complaints of pelvic pain. The nurse should expect the client to have:
Correct Answer: A
Rationale: Endometriosis causes pelvic pain and dysmenorrhea due to ectopic endometrial tissue responding to hormonal changes.