ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
Correct Answer: D
Rationale: The correct answer is D: Immediately stop the transfusion, infuse normal saline solution, notify the blood bank. Rationale: 1. Stop the transfusion immediately to prevent further complications from the hemolytic reaction. 2. Infuse normal saline solution to maintain adequate hydration and support kidney function. 3. Notify the blood bank to report the adverse reaction and to return the blood products for further investigation and testing. Summary of other choices: A: Incorrect because infusing dextrose 5% in water (D5W) is not indicated for treating a hemolytic reaction. Calling the physician is important, but stopping the transfusion and notifying the blood bank are more critical. B: Incorrect because slowing the transfusion may not be sufficient to manage the acute hemolytic reaction effectively. C: Incorrect because administering antihistamines is not the appropriate treatment for a hemolytic reaction. Stopping the transfusion and notifying the blood bank are more urgent actions.
Question 2 of 5
Which of the following terms indicates that the patient has a hearing loss caused by aging?
Correct Answer: B
Rationale: The correct answer is B: Presbycusis. Presbycusis refers to age-related hearing loss, commonly affecting higher frequencies. As people age, changes in the inner ear structures can lead to hearing loss. Otoplasty (A) is a surgical procedure to correct ear deformities, not related to aging. Otalgia (C) refers to ear pain, not specifically related to aging. Tinnitus (D) is the perception of ringing or buzzing in the ears, which can occur at any age and is not exclusive to age-related hearing loss.
Question 3 of 5
A few hours before the patient was admitted at the hospital, he complained of fever, nausea and vomiting, and vague abdominal pain. The doctor examined the patient as a case of acute appendicitis and prepared for appendectomy. The nurse anticipates that this type of surgery is classified as:
Correct Answer: A
Rationale: The correct answer is A: emergency. Acute appendicitis is a condition that requires immediate surgical intervention to prevent complications like rupture. In an emergency surgery, the procedure must be done urgently to treat a life-threatening condition. In this case, the patient's symptoms indicate an urgent need for surgery to remove the inflamed appendix. Choice B: urgent, implies that surgery is needed promptly, but not immediately to prevent life-threatening complications. Choice C: elective, refers to a planned, non-urgent surgery that is scheduled in advance. Choice D: required, is a vague term and doesn't specify the urgency of the surgery, hence it is not the best classification for acute appendicitis surgery.
Question 4 of 5
A client has cancer that has me tastasized to her bones. She is complaining of increased thirst, polyuria and decreased muscle tone. Her lab values are: Na 139mEq/L, k 4 mEq/L, Cl 103 mEq/L, and Ca 8 mg/dl. What electrolyte imbalance is present?
Correct Answer: C
Rationale: The correct answer is C: Hypercalcemia. Increased thirst and polyuria are symptoms of hypercalcemia, as excess calcium can lead to dehydration and increased urine output. Decreased muscle tone is also a common symptom of hypercalcemia. The lab value of Ca 8 mg/dl confirms high levels of calcium in the blood. Incorrect choices: A: Hypocalcemia - This is incorrect as the lab value of Ca 8 mg/dl indicates normal to high levels of calcium, ruling out hypocalcemia. B: Hyperkalemia - This is incorrect as the lab value of K 4 mEq/L is within normal range, ruling out hyperkalemia. D: Hypochloremia - This is incorrect as the lab value of Cl 103 mEq/L is within normal range, ruling out hypochloremia.
Question 5 of 5
A patient is admitted to a medical unit with a diagnosis of heart failure. The patient reports that she has had increasing fatigue during the past 2 weeks. Which of the following is the most likely cause of this fatigue?
Correct Answer: B
Rationale: The correct answer is B: Decreased cardiac output. Fatigue in heart failure is primarily due to decreased cardiac output, leading to reduced oxygen and nutrient delivery to tissues, causing fatigue. Dyspnea (A) is shortness of breath, not fatigue. Dry cough (C) is more associated with conditions like pulmonary issues, not fatigue. Orthopnea (D) is difficulty breathing while lying down, not specifically related to fatigue. Hence, decreased cardiac output is the most likely cause of fatigue in this patient.