NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 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 2 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 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
A client with severe anemia is to receive a unit of packed red blood cells. In the event of a transfusion reaction, the first action by the nurse should be to:
Correct Answer: B
Rationale: Stopping the transfusion and maintaining an IV of normal saline is the first action to prevent further reaction and stabilize the client.
Question 5 of 5
The nurse is preparing to administer a dose of gentamicin (Garamycin) IV. Which laboratory value should the nurse check before administration?
Correct Answer: A
Rationale: Gentamicin is nephrotoxic, so serum creatinine is checked to assess kidney function before administration to prevent toxicity. Other labs are less directly related to gentamicin risks.