NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse recognizes that a client with the diagnosis of cholecystitis and cholelithiasis would expect to have stools that are:
Correct Answer: A
Rationale: Clients who have obstruction in the biliary tract so that bile is not released into the duodenum experience a change in stools from brown to gray or clay colored. This type of stool can occur with other GI problems, such as bacterial or viral infections, and other disease problems, and is not a common finding with biliary obstructions such as cholecystitis and cholelithiasis. This type of stool is usually associated with a GI or bowel problem, such as lower GI bleeding, rather than with biliary obstructions. This type of stool is usually associated with a GI or bowel problem, such as upper GI bleeding, rather than with biliary obstructions.
Question 2 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 3 of 5
The nurse has just received the change of shift report. Which client should the nurse assess first?
Correct Answer: A
Rationale: The client two hours post-lobectomy with 150mL of chest drainage is at risk for complications such as hemorrhage or tension pneumothorax, requiring immediate assessment. The other clients are stable: scant drainage is expected post-gastrectomy, a fever in pneumonia is concerning but less urgent, and a fractured hip in traction is typically stable.
Question 4 of 5
The nurse instructs a client on the difference between true labor and false labor. The nurse explains, 'In true labor:
Correct Answer: B
Rationale: In true labor, uterine contractions strengthen and become more regular with activity like walking, facilitating cervical dilation and fetal descent.
Question 5 of 5
The nurse is caring for a client with a history of a mastectomy. The client complains of arm swelling. The nurse should:
Correct Answer: B
Rationale: Arm swelling post-mastectomy suggests lymphedema, and elevating the arm reduces fluid accumulation. Warm compresses and massage may worsen swelling, and notification is secondary.