NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
When the nurse is evaluating lab data for a client 18-24 hours after a major thermal burn, the expected physiological changes would include which of the following?
Correct Answer: D
Rationale: Hematocrit is elevated due to hemoconcentration from hypovolemia. Sodium, calcium, and protein levels are typically decreased due to losses into edema fluid or increased capillary permeability.
Question 2 of 5
When the nurse is evaluating lab data for a client 18-24 hours after a major thermal burn, the expected physiological changes would include which of the following?
Correct Answer: D
Rationale: Hematocrit is elevated due to hemoconcentration from hypovolemia. Sodium, calcium, and protein levels are typically decreased due to losses into edema fluid or increased capillary permeability.
Question 3 of 5
A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:
Correct Answer: A
Rationale: Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and survival is likely.
Question 4 of 5
The nurse is preparing to administer a dose of morphine sulfate IV to a client for pain. Which assessment is most important before administration?
Correct Answer: A
Rationale: Morphine, an opioid, can cause respiratory depression. Assessing the respiratory rate is critical before administration to ensure it is above 12 breaths per minute, preventing overdose risk. Other vital signs are monitored but are less critical.
Question 5 of 5
A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?
Correct Answer: B
Rationale: These delusions are related to the belief that an individual has an incurable illness. These delusions are related to feelings of self-importance and uniqueness. These delusions are related to feelings of being conspired against. These delusions are related to denial of self-existence.