NCLEX Questions, ATI NCLEX-RN Practice Questions Questions,

Extract:

Question 1 of 5

The physician has prescribed Coumadin (sodium warfarin) for a client having transient ischemic attacks. Which laboratory test measures the therapeutic level of Coumadin?

Correct Answer: A

Rationale: Prothrombin time (PT/INR) measures Coumadin's anticoagulant effect by assessing clotting time. PTT monitors heparin, and clot retraction or bleeding time are unrelated.

Question 2 of 5

Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:

A. The physician orders it B. A therapeutic alliance has been established, and violent behavior subsides C. The violent behavior subsides, and the client agrees to behave D. The nurse deems that removal of restraints is necessary

Correct Answer: B

Rationale: While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence.

Question 3 of 5

On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:

A. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes B. Allow the infant to breast-feed at the next feeding time to empty the breasts C. Apply ice packs to the breasts and wear a supportive, well-fitting bra D. Take a warm shower and express milk from both breasts until empty

Correct Answer: C

Rationale: Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. Breast-feeding every 1Â½-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottle-feeding mother. Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.

Question 4 of 5

A client's physician has prescribed theophylline (Theo-Dur) to help control the bronchospasm associated with the client's COPD. Instructions that should be given to the client include:

A. Call your physician if you develop palpitations, dizziness, or restlessness. B. Cigarette smoking may significantly increase the risk for theophylline toxicity. C. Take this medication on an empty stomach. D. Do not take your medicine if your pulse is less than 60 beats per minute.

Correct Answer: A

Rationale: Theophylline toxicity can manifest as palpitations, dizziness, or restlessness, requiring immediate medical attention.

Question 5 of 5

A 1000-mL dose of lactated Ringer's solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse administer?

Your Answer:

Correct Answer: D

Rationale: 20.8, or 21 gtt/min.