ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 9
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
Correct Answer: D
Rationale: Step 1: Proper positioning helps maintain alignment and prevent deformities in muscles and joints. Step 2: It reduces the risk of contractures by ensuring that Mr. Gabatan's lower extremities are in optimal positions. Step 3: This promotes circulation and reduces pressure on bony prominences. Step 4: Active exercise may exacerbate spasticity, tilt board may not address positioning adequately, and deep massage may not prevent contractures effectively.
Question 2 of 9
The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus?
Correct Answer: A
Rationale: The correct answer is A: antidiuretic hormone (ADH). In diabetes insipidus, there is a deficiency of ADH, which regulates water balance by reducing urine output. Without ADH, excessive urination and thirst occur. FSH, TSH, and LH are not related to water balance regulation. FSH and LH are involved in reproductive functions, while TSH regulates thyroid hormone production. Therefore, the nurse should focus on educating the client about the importance of ADH in managing diabetes insipidus.
Question 3 of 9
When preparing a site for venipunctures with alcohol, how long must the area be cleaned?
Correct Answer: D
Rationale: The correct answer is D: 60 seconds. This is because the area must be cleaned for at least 60 seconds to effectively disinfect the skin and reduce the risk of infection during venipuncture. Cleaning for shorter durations (5, 10, or 30 seconds) may not be sufficient to achieve proper disinfection. Thoroughly cleaning the area for a full minute ensures that the alcohol has enough time to kill bacteria and pathogens on the skin, making it safer for the venipuncture procedure. Shorter cleaning times may leave pathogens behind, increasing the risk of contamination and infection.
Question 4 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 5 of 9
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
Correct Answer: D
Rationale: Step 1: Proper positioning helps maintain alignment and prevent deformities in muscles and joints. Step 2: It reduces the risk of contractures by ensuring that Mr. Gabatan's lower extremities are in optimal positions. Step 3: This promotes circulation and reduces pressure on bony prominences. Step 4: Active exercise may exacerbate spasticity, tilt board may not address positioning adequately, and deep massage may not prevent contractures effectively.
Question 6 of 9
A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate of 8 breaths/min. Morphine is an opioid that can cause respiratory depression as a side effect. A respiratory rate of 8 breaths/min indicates hypoventilation, which is a potential adverse effect of morphine. This is a critical finding that requires immediate intervention to prevent respiratory failure or arrest. A: Voiding of 350mL of concentrated urine in 8 hours is not directly related to morphine's adverse effects. Morphine can cause urinary retention, not increased voiding. C: Irregular heart rate of 82 beats/min is within normal range and not a typical adverse effect of morphine. Morphine can cause bradycardia or tachycardia, but not irregular heart rate specifically. D: Pupils constricted and equal is a common side effect of morphine due to its effect on the central nervous system. This finding does not suggest an adverse effect; it is an expected pharmac
Question 7 of 9
A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?
Correct Answer: C
Rationale: Correct Answer: C - Tracheostomy set Rationale: 1. Immediate airway management: After thyroidectomy, there is a risk of airway compromise due to swelling or bleeding. Tracheostomy set ensures immediate access to secure the airway. 2. Emergency intervention: In case of respiratory distress or airway obstruction post-surgery, a tracheostomy set allows for prompt and effective intervention. 3. Patient safety and priority: Ensuring airway patency is crucial for the client's survival and takes precedence over other equipment. Summary of other choices: A: Indwelling urinary catheter kit - Not directly related to post-thyroidectomy care. B: Cardiac monitor - Important but secondary to airway management in this situation. D: Humidifier - Not essential for immediate post-thyroidectomy care.
Question 8 of 9
Which of the ff conditions is evident by persistent hoarseness?
Correct Answer: C
Rationale: The correct answer is C: Laryngeal cancer. Persistent hoarseness is a common symptom of laryngeal cancer due to vocal cord involvement. Laryngeal cancer causes changes in voice quality over time. Bacterial infection (A) usually presents with acute symptoms and resolves with treatment. Aphonia (B) is the complete loss of voice, not persistent hoarseness. Peritonsillar abscess (D) causes sore throat and difficulty swallowing, but not persistent hoarseness.
Question 9 of 9
A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client’s urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?
Correct Answer: D
Rationale: The correct answer is D: Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large volumes of dilute urine. This results in low urine osmolality as the kidneys are unable to concentrate the urine. On the other hand, the serum osmolality increases due to the lack of ADH causing water retention. Therefore, the laboratory findings of low urine osmolality and high serum osmolality support the diagnosis of diabetes insipidus. Explanation for other choices: A: Above-normal urine and serum osmolality levels - This does not align with the pathophysiology of diabetes insipidus. B: Below-normal urine and serum osmolality levels - This is incorrect as low serum osmolality is not characteristic of diabetes insipidus. C: Above-normal urine osmolality level, below-normal