ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 9
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 9
The best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:
Correct Answer: D
Rationale: The correct answer is D, "Chest and nostrils." This is because observing the movement of the chest and nostrils is the most reliable way to determine if a patient is breathing. The chest rises and falls with each breath, and the nostrils may flare or move as air is inhaled and exhaled. Monitoring these areas provides a direct indication of respiratory effort. Choices A, B, and C are incorrect because they do not directly reflect the act of breathing. Extremities, head, and eyeball movements are not reliable indicators of breathing function.
Question 3 of 9
Which of the ff does the examiner note when auscultating the lungs of a client with pleural effusion?
Correct Answer: D
Rationale: The correct answer is D because pleural effusion is the accumulation of fluid in the pleural space. When auscultating the lungs of a client with pleural effusion, the examiner would note decreased or absent breath sounds over the area where the fluid has accumulated. This is due to the fluid blocking the transmission of sound through the lungs. Pronounced breath sounds (choice A) would not be present due to the fluid obstructing the normal sound transmission. Expiratory wheezes (choice B) are associated with airway obstruction, not fluid accumulation. Friction rub (choice C) is a dry, grating sound heard with inflammation of the pleura, not specifically related to pleural effusion.
Question 4 of 9
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Correct Answer: A
Rationale: The correct answer is A: Completes a comprehensive database. During the first phase of the nursing process (assessment), the nurse collects data to establish a comprehensive database of the patient's health status. This information serves as the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities (C) in the third phase (planning), and determining outcomes achieved (D) in the fourth phase (evaluation). Completing a comprehensive database is crucial in the initial assessment phase to gather accurate information for the subsequent steps in the nursing process.
Question 5 of 9
The lungs regulate acid-base balance b₃y⁻ all of the following except:
Correct Answer: C
Rationale: The correct answer is C: Slowing ventilation. The lungs regulate acid-base balance by controlling carbon dioxide levels through ventilation. Increasing ventilation helps expel excess carbon dioxide, thus regulating pH. Slowing ventilation would lead to CO2 buildup and an imbalance in acid-base levels. Excreting HCO3- into the blood (choice A) helps maintain pH, while increasing ventilation (choice D) aids in removing excess CO2. Therefore, slowing ventilation is the exception as it would disrupt the acid-base balance by not effectively regulating carbon dioxide levels.
Question 6 of 9
A client is brought to the emergency department unconscious after a fall. What is the primary source of information in this case?
Correct Answer: A
Rationale: The correct answer is A: Client's spouse. In the case of an unconscious client, the spouse is the primary source of information about the client's medical history, medications, allergies, and recent events. This information is crucial for providing appropriate care. Medical records may not be immediately accessible. Diagnostic tests provide limited historical information. Nursing assessment relies on the client's condition, which may not provide comprehensive information.
Question 7 of 9
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 8 of 9
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? This question corresponds to the "P" in PQRST, which stands for Provocation/Palliation. By asking where the pain is located, the nurse is gathering information about what triggers or relieves the pain, aiding in the assessment of the chest pain. The other choices are incorrect because: B: What causes the pain? - This question corresponds to the "Q" in PQRST, which stands for Quality. It focuses on understanding the characteristics of the pain, not the cause. C: Does it come and go? - This question corresponds to the "R" in PQRST, which stands for Radiation. It pertains to whether the pain spreads to other areas, not if it comes and goes. D: What does the pain feel like? - This question corresponds to the "S" in PQRST, which stands for Severity. It relates to the intensity of the pain, not its location.
Question 9 of 9
A brain abscess is a collection of pus within the substance of the brain and is caused by:
Correct Answer: D
Rationale: The correct answer is D because a brain abscess can be caused by direct invasion of the brain, spread of infection by other organs, and spread of infection from nearby sites. Direct invasion occurs when bacteria enter the brain tissue directly, such as through trauma or surgery. Infections from other organs, like the lungs or heart, can spread through the bloodstream to the brain. Infections from nearby sites, such as the ears or sinuses, can also spread to the brain. Therefore, all of these mechanisms can lead to the formation of a brain abscess. Choices A, B, and C individually do not cover all the possible causes of a brain abscess, making D the correct choice.