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 nurse is caring for a patient with HIV who has diarrhea. Which of the following would be most therapeutic to teach the patient to avoid in the diet to reduce diarrhea?
Correct Answer: C
Rationale: The correct answer is C: Raw fruits and vegetables. Patients with HIV and diarrhea should avoid raw fruits and vegetables due to their high fiber content, which can exacerbate diarrhea symptoms. Fiber can increase bowel movements and worsen diarrhea. Therefore, avoiding raw fruits and vegetables can help reduce diarrhea. Choice A (Potassium-rich food) is not the best answer because potassium-rich foods are important for patients with HIV to maintain electrolyte balance. Choice B (Liquid nutritional supplements) can actually be beneficial in providing essential nutrients to patients with HIV. Choice D (Frozen products) is not directly related to diarrhea management in patients with HIV.
Question 3 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.
Question 4 of 9
Which of the following intravenous solutions is hypotonic?
Correct Answer: C
Rationale: The correct answer is C: 0.45% saline. This solution is hypotonic because it has a lower osmolarity compared to the intracellular fluid. It contains fewer solutes than the cells, causing water to move into the cells by osmosis, potentially causing them to swell. Normal saline (A) and Ringer's lactate (B) are isotonic solutions, meaning they have a similar osmolarity to the intracellular fluid and do not cause significant water shifts. 5% dextrose in normal saline (D) is a hypertonic solution, containing more solutes than the cells, leading to water movement out of the cells.
Question 5 of 9
Which of the ff. is a symptom that the nurse would expect to find during assessment of a patient experiencing acute angle-closure glaucoma?
Correct Answer: C
Rationale: The correct answer is C: Halos around lights. This symptom is specific to acute angle-closure glaucoma due to increased intraocular pressure causing corneal edema. Halos around lights are caused by light diffraction through edematous cornea. Flashing lights and lens opacity are not typically associated with acute angle-closure glaucoma. Flashing lights may be seen in retinal detachment, while lens opacity is more commonly seen in cataracts.
Question 6 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 7 of 9
Which of the ff is a nursing intervention when assessing clients with hypertension?
Correct Answer: B
Rationale: The correct answer is B because teaching the client about both non-pharmacologic and pharmacologic methods for managing hypertension is a crucial nursing intervention to empower the client in their self-care and treatment plan. This intervention helps the client understand the importance of lifestyle modifications and medication adherence in controlling blood pressure. A: The nurse taking the temperature in different positions is not directly related to assessing hypertension. C: Taking BP in different positions is important for orthostatic hypotension, not specifically for hypertension. D: Weighing the client each morning is not a direct nursing intervention for assessing hypertension.
Question 8 of 9
Which of the ff nursing interventions is essential for a client during the Schilling test?
Correct Answer: A
Rationale: The correct answer is A because collecting urine 24-48 hrs after the client has received nonradioactive B12 is essential for the Schilling test to evaluate vitamin B12 absorption. Urine is collected to measure the excretion of radioactive B12, which helps in diagnosing pernicious anemia or malabsorption issues. Incorrect choices: B: Collecting blood samples is not necessary for the Schilling test as it primarily involves urine collection. C: Allowing oral fluid consumption is important to prevent dehydration and is not contraindicated after receiving nonradioactive B12. D: Making the client lie down in the supine position is unnecessary for the Schilling test and may not affect the test results.
Question 9 of 9
The activation of B cells in humoral immunity is assisted by which of the following?
Correct Answer: C
Rationale: The correct answer is C: Helper T cells. Helper T cells play a crucial role in activating B cells by releasing cytokines that stimulate B cell proliferation and differentiation. They also help in the production of antibodies. Cytotoxic T cells (A) are involved in cell-mediated immunity, not humoral immunity. Suppressor T cells (B) regulate the immune response and do not directly assist in B cell activation. Neutrophils (D) are phagocytic cells involved in innate immunity, not in activating B cells in humoral immunity.