NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for an eight-year-old following a routine tonsillectomy. Which finding should be reported immediately?
Correct Answer: D
Rationale: Respiratory stridor post-tonsillectomy suggests airway obstruction, a life-threatening complication requiring immediate reporting. The other findings are normal or less urgent.
Question 2 of 5
A client is admitted to the emergency room with partial-thickness burns to his right arm and full-thickness burns to his trunk. According to the Rule of Nines, the nurse calculates that the total body surface area (TBSA) involved is:
Correct Answer: B
Rationale: Per the Rule of Nines, the right arm is 9% and the trunk (anterior and posterior) is 36%. Partial- and full-thickness burns to the right arm and trunk approximate 35% TBSA.
Question 3 of 5
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
Correct Answer: B
Rationale: Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. Increased cardiac output results as fluids shift back to the vascular compartment. Hypertension is the result of hypervolemia.
Question 4 of 5
The nurse is caring for a client with a history of a diabetic foot ulcer. The nurse should:
Correct Answer: B
Rationale: Elevating the foot reduces swelling and promotes healing in a diabetic foot ulcer. Heating pads, soaking, and massage increase infection risk or impair circulation.
Question 5 of 5
The nurse is caring for a client with a diagnosis of ectopic pregnancy. Which diagnostic test is most likely to be ordered?
Correct Answer: C
Rationale: Ultrasound confirms the location of the pregnancy (e.g. outside the uterus) and serial serum hCG levels help diagnose ectopic pregnancy by showing abnormal doubling patterns. Both tests are commonly ordered.