ATI NCLEX-RN Practice Questions

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Question 1 of 5.

A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:

A. Control the delivery by guiding expulsion of fetus

B. Leave the room to call the physician

C. Push against the perineum to stop delivery

D. Cross client's legs tightly

Explanation: Guiding the fetus's expulsion during a precipitous delivery minimizes injury and perineal trauma.

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.

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A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be: