NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
Which of the following nursing orders has the highest priority for a child with epiglottitis?
Correct Answer: B
Rationale: Because of the possibility of fever or respiratory failure, vital signs should be done more often than every eight hours. If the epiglottitis worsens, the edema and laryngospasm may close the airway and an emergency tracheostomy may be necessary. Although intake and output are a part of the nursing care of a child with epiglottitis, it is not as important as the safety measure of keeping the tracheostomy set at the bedside. Specific gravity will indicate hydration status, but it is not as important as keeping the tracheostomy set at the bedside.
Question 2 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 3 of 5
A client with a history of rheumatoid arthritis is admitted with complaints of joint swelling. The nurse should give priority to:
Correct Answer: A
Rationale: Anti-inflammatories reduce joint swelling and pain in rheumatoid arthritis, improving function.
Question 4 of 5
The client is diagnosed with a retinal detachment. Which symptom is most likely reported by the client?
Correct Answer: A
Rationale: Retinal detachment typically causes sudden vision loss, often described as a curtain over the visual field. Pain, redness, and double vision are less common.
Question 5 of 5
A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect. Based on his developmental stage, the nurse:
Correct Answer: B
Rationale: A toddler is not capable of conceptualizing about the inside of his body and is concerned about body intactness; therefore, diagrams would not be useful. Also, the previous evening is too far from the procedure for the toddler to remember the instructions. A simple explanation the morning of the procedure is the best developmental strategy to use, because it focuses on the toddler's need for parental support, body intactness, and short attention span. A relationship between the nurse and the child needs to develop. Also, misinformation may be given to the child if the parents explain the procedure to the child. The parents are the child's support system and need to be there to strengthen the child.