ATI NCLEX-RN Practice Questions
Question 1 of 5.
A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?
A. Altered nutrition: less than body requirements related to inability to take in adequate calories
B. Altered growth and development related to decreased intake of food
C. Activity intolerance related to imbalance between oxygen supply and demand
D. Decreased cardiac output related to ineffective pumping action of the heart
Explanation: Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. The decreased intake occurs due to fatigue from the altered cardiac output. Fatigue occurs due to the decreased cardiac output. The ineffective action of the myocardium leads to inadequate O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development.
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.