NCLEX-RN
ATI NCLEX-RN Practice Questions Questions
Extract:
Question 1 of 5
Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax?
Correct Answer: C
Rationale: The tension pneumothorax acts like a one-way valve so that the pneumothorax increases with each breath. Eventually, it occupies enough space to shift mediastinal tissue toward the unaffected side away from the midline. Tracheal deviation, movement of point of maximum impulse, and decreased cardiac output will occur. The other three options will occur in both types of pneumothorax.
Question 2 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 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 caring for a client with a suspected hip fracture. Which intervention should be implemented to prevent complications?
Correct Answer: C
Rationale: Immobilizing the hip with a splint prevents further injury and reduces pain in a suspected hip fracture. Heating pads, dependent positioning, and weight-bearing can worsen the injury.
Question 5 of 5
Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
Correct Answer: B
Rationale: Four-year-olds are at greatest risk for accidental poisoning due to their curiosity, increased mobility, and ability to access household items, combined with limited understanding of danger. One-year-olds have less mobility, while eight- and twelve-year-olds have better cognitive awareness to avoid hazards.