NCLEX NCLEX-PN
Next Generation Nclex Questions Overview 3.0 ATI Quizlet
1. Why is padding on a restraint helpful?
- A. To distribute pressure so that bony prominences do not receive pressure when a client pulls against the restraints.
- B. To help the client feel more secure.
- C. To keep infection and wounds at bay.
- D. To keep restraints in place.
Correct answer: To distribute pressure so that bony prominences do not receive pressure when a client pulls against the restraints.
Rationale: Padding on a restraint helps distribute pressure to prevent bony prominences from bearing excessive pressure when a client pulls against the restraints. This is crucial to avoid tissue damage caused by ischemia. The correct answer focuses on the physiological benefit of padding in reducing pressure on vulnerable areas to prevent harm. Choice B is incorrect as the primary purpose of padding is not emotional comfort but preventing physical harm. Choice C is incorrect as while padding can indirectly help prevent infection and wounds by reducing pressure, its primary function is pressure distribution. Choice D is incorrect as the main purpose of padding is not to keep the restraints in place but to protect the client's skin and tissues from pressure-related injuries.
2. While Fluorouracil (5FU®) is being infused, a client complains of burning at the IV site. What should the nurse do first?
- A. Aspirate the IV site for blood return.
- B. Slow the infusion.
- C. Inspect the IV site.
- D. Stop the infusion.
Correct answer: C
Rationale: The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (Choice A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (Choice B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (Choice D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.
3. A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?
- A. Consider it a normal finding.
- B. Check the system for leaks.
- C. Clamp the chest tube.
- D. Change the drainage system.
Correct answer: Consider it a normal finding.
Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak. Checking the system for leaks would be appropriate if there is continuous, excessive bubbling. Clamping the chest tube or changing the drainage system is not necessary in response to a small amount of bubbling during a cough, as this is considered a normal finding.
4. One drug can alter the absorption of another drug. One drug increases intestinal motility. Which effect does this have on the second drug?
- A. None; absorption of the second drug is not affected.
- B. The increased gut motility decreases the absorption of the second drug.
- C. The absorption of the second drug cannot be predicted.
- D. Less of the second drug is absorbed.
Correct answer: Less of the second drug is absorbed.
Rationale: When one drug increases intestinal motility, it accelerates the movement of the second drug through the system. Since most oral medications are absorbed in the intestine, the faster transit time decreases the absorption of the second drug. Therefore, less of the second drug is absorbed. Choice A is incorrect because the increased gut motility does affect the absorption of the second drug. Choice C is incorrect as the effect of increased intestinal motility on drug absorption can be predicted based on pharmacokinetic principles. Choice B is incorrect as increased gut motility would not increase but decrease the absorption of the second drug.
5. When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:
- A. “There is some evidence that ginseng may enhance in vitro sperm motility.”
- B. “Some studies show that ginseng enhances in vitro sperm motility.”
- C. “Ginseng is not proven to be effective for infertility; have you considered other options?”
- D. “It’s probably not going to hurt you, but it’s also probably not going to help. Let’s look at some other alternatives.”
Correct answer: “Some studies show that ginseng enhances in vitro sperm motility.”
Rationale: Some studies have shown that ginseng enhances in vitro sperm motility, making Choice B the correct response. It directly addresses the client’s comments about taking ginseng and provides valuable information regarding its potential effect on sperm motility. Alternative therapies are often sought by couples struggling with infertility, and acknowledging the potential benefits of ginseng can empower the client. Choice A is incorrect as it slightly misrepresents the evidence by overgeneralizing its effectiveness. Choice C dismisses ginseng without acknowledging its potential benefits, potentially closing off a fruitful discussion with the client. Choice D, while neutral, misses the opportunity to validate the client's choice and explore further options collaboratively. It is crucial for nurses to respect clients' choices, provide accurate information, and guide them effectively in exploring different alternatives.
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