ATI NCLEX-RN Practice Questions
Question 1 of 5.
A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis--Alteration in comfort, pain related to:
A. Increased excretion of lactic acid due to myocardial hypoxia
B. Increased blood flow through the coronary arteries
C. Decreased stimulation of the sympathetic nervous system
D. Decreased secretion of catecholamines secondary to anxiety
Explanation: Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed toward increasing the blood flow through coronary arteries. Chest pain causes an increase in the stimulation of the sympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasing the workload of the heart.
Question 2 of 5.
Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
A. Change the dressings once per shift.
B. Moisten the dressing with sterile water.
C. Change the dressings only when they become soiled.
D. Moisten the dressing with normal saline.
Explanation: Acticoat dressings require moistening with normal saline to activate the silver ions for antimicrobial action and to maintain a moist healing environment.
Question 3 of 5.
A client hospitalized for treatment of congestive heart failure is to be discharged with a prescription for Digitek (digoxin) 0.25 mg daily. Which of the following statements indicates that the client needs further teaching?
A. I will need to take the medication at the same time each day.
B. I can prevent stomach upset by taking the medication with an antacid.
C. I can help prevent drug toxicity by eating foods containing fiber.
D. I will need to report visual changes to my doctor.
Explanation: Taking digoxin with an antacid can decrease its absorption, reducing effectiveness, so this statement indicates a need for further teaching.
Question 4 of 5.
A client is admitted to the emergency room with partial-thickness burns to his right arm and full-thickness burns to his trunk. According to the Rule of Nines, the nurse calculates that the total body surface area (TBSA) involved is:
A. 20%
B. 35%
C. 45%
D. 60%
Explanation: Per the Rule of Nines, the right arm is 9% and the trunk (anterior and posterior) is 36%. Partial- and full-thickness burns to the right arm and trunk approximate 35% TBSA.
Question 5 of 5.
A client with severe anemia is to receive a unit of packed red blood cells. In the event of a transfusion reaction, the first action by the nurse should be to:
A. Notify the physician and the nursing supervisor.
B. Stop the transfusion and maintain an IV of normal saline.
C. Call the lab for verification of type and cross match.
D. Prepare an injection of Benadryl (diphenhydramine).
Explanation: Stopping the transfusion and maintaining an IV of normal saline is the first action to prevent further reaction and stabilize the client.