NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?
Correct Answer: A
Rationale: Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion prevents worsening overload. Stopping it (
C) is premature, documenting only (
B) delays intervention, and pupil assessment (
D) is irrelevant.
Question 2 of 5
A client is admitted with kidney disease. Which type of intravenous fluid is likely to be ordered for this client?
Correct Answer: B
Rationale: Isotonic fluids (e.g. 0.9% normal saline) are typically used in kidney disease to maintain fluid balance without overloading or stressing impaired kidneys. Hypertonic or hypotonic fluids may disrupt electrolyte balance and colloids are used for specific indications like shock.
Question 3 of 5
The best indicator of peripheral edema is determined by:
Correct Answer: D
Rationale: Checking for pitting (indentation after pressing the skin) is the most direct and reliable indicator of peripheral edema. While weight extremity measurement and intake/output are relevant pitting specifically confirms edema.
Question 4 of 5
A two-year-old is being evaluated for hearing loss. Which finding in the child's history is likely to be a significant factor?
Correct Answer: D
Rationale: Meningitis treated with garamycin (gentamicin) is a significant risk factor for hearing loss as gentamicin is ototoxic and meningitis can damage auditory nerves. The other factors are less directly associated with hearing impairment.
Question 5 of 5
Other drugs may be ordered to manage a client's ulcerative colitis. Which of the following medications, if ordered, would the nurse question?
Correct Answer: D
Rationale: 6-Mercaptopurine is used for Crohn's disease, not ulcerative colitis, so the nurse should question its order.