NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 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 2 of 5
The client at 38 weeks gestation is admitted with a blood pressure of 150/100,proteinuria and edema. The nurse should prepare to administer which of the following medications?
Correct Answer: A
Rationale: The client’s symptoms (hypertension proteinuria edema) indicate preeclampsia. Magnesium sulfate is administered to prevent seizures (eclampsia). Terbutaline is a tocolytic hydralazine treats hypertension and betamethasone is for fetal lung maturity in preterm labor.
Question 3 of 5
A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?
Correct Answer: C
Rationale: Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt. Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. Activity instructions include: avoid sitting for long periods and get exercise by walking. Lifting more than 5 lb of weight is also prohibited. The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization. A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations.
Question 4 of 5
The nurse is caring for a client with a history of breast cancer who is receiving Tamoxifen (Nolvadex). The nurse should monitor the client for:
Correct Answer: A
Rationale: Tamoxifen, an anti-estrogen, commonly causes hot flashes due to hormonal changes. Blood pressure, appetite, and hair loss are not primary side effects.
Question 5 of 5
The nurse is caring for a client with a suspected hip fracture. Which intervention should be implemented to prevent complications?
Correct Answer: C
Rationale: Immobilizing the hip with a splint prevents further injury and reduces pain in a suspected hip fracture. Heating pads, dependent positioning, and weight-bearing can worsen the injury.