ATI NCLEX-RN Practice Questions
Question 1 of 5.
On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
A. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes
B. Allow the infant to breast-feed at the next feeding time to empty the breasts
C. Apply ice packs to the breasts and wear a supportive, well-fitting bra
D. Take a warm shower and express milk from both breasts until empty
Explanation: Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. Breast-feeding every 1½-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottle-feeding mother. Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.
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.