NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A 3-month-old is admitted to the pediatric unit with moderate dehydration. The nurse should assess the client for:
Correct Answer: B, C
Rationale: Moderate dehydration in an infant is indicated by a rapid, thready pulse and decreased skin elasticity due to fluid loss.
Question 2 of 5
When assessing for signs of a blood transfusion reaction in a client with dark skin, the nurse should assess for which of the following?
Correct Answer: B
Rationale: Diaphoresis is a visible sign of a transfusion reaction, detectable regardless of skin tone, indicating an acute response.
Question 3 of 5
A client is being discharged from the hospital after removal of chest tubes that were inserted following thoracic surgery. When providing home care instructions to the client, which client statement indicates a need for further teaching?
Correct Answer: C
Rationale: Upon removal of a chest tube, a dressing is usually placed over the chest tube site. This is maintained in place until the primary health care provider says it may be removed. The client should avoid heavy lifting for the first 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any respiratory difficulty or increased temperature.
Question 4 of 5
A client with a history of atrial fibrillation is prescribed digoxin (Lanoxin). The nurse should teach the client to report which of the following symptoms as a potential sign of toxicity?
Correct Answer: B
Rationale: Yellow-green visual halos are a classic sign of digoxin toxicity, indicating the need for immediate medical evaluation.
Question 5 of 5
An Hispanic mother who does not speak English and is very upset brings her child to the clinic with bleeding from the mouth. Which of the following is the most appropriate action by the nurse who does not speak Spanish?
Correct Answer: A
Rationale: Calling an interpreter ensures accurate communication, addressing the mother's distress and obtaining a clear history.