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 has begun to exhibit signs of alcohol withdrawal. Her blood pressure has risen from 120/60 to 190/100, pulse is increased from 88 to 110 bpm, and she is irritable and agitated and has gross motor tremors of the hands. The nurse notifies the doctor. The nurse can anticipate that the doctor will order which of the following?
Correct Answer: B
Rationale: This answer is incorrect. Benzodiazepines are drugs of choice for alcohol withdrawal. This answer is correct. The drug has a sedative effect, is safe, and has an anticonvulsant effect. This answer is incorrect. Amitriptyline is an antidepressant. This answer is incorrect. Chlorpromazine is most effective in psychotic disorders.
Question 3 of 5
The nurse is caring for a client with a history of a seizure disorder who is receiving Lamotrigine (Lamictal). The nurse should monitor the client for:
Correct Answer: A
Rationale: Lamotrigine can cause a serious rash, including Stevens-Johnson syndrome, requiring immediate monitoring and reporting. Hypotension, hyperglycemia, and weight gain are not primary concerns.
Question 4 of 5
The physician has ordered atropine sulfate 0.4 milligrams IM before surgery. The medication is supplied in 0.8 milligrams per milliliter. How much medication should the nurse prepare to administer?
Correct Answer: 0.5
Rationale:
To calculate: 0.4 mg desired ÷ 0.8 mg/mL = 0.5 mL. The nurse should prepare 0.5 mL of atropine sulfate.
Question 5 of 5
When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:
Correct Answer: D
Rationale: Tube feedings should be withheld and physician notified for residual volumes of 50-100 mL.