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
A client with a history of atrial fibrillation is prescribed amiodarone (Cordarone). Which side effect should the nurse monitor for?
Correct Answer: A
Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect manifesting as cough or dyspnea, requiring regular monitoring.
Question 3 of 5
A client is admitted to the inpatient unit and is exhibiting pressured speech, a labile affect, euphoria, and hyperactivity. The client states, 'I am the Savior of the city.' The family states that the client is a public client in the United States. The nurse should further assess the client for which of the following?
Correct Answer: B
Rationale: Pressured speech, labile affect, euphoria, hyperactivity, and grandiose delusions (e.g., 'Savior of the city') are hallmark symptoms of the manic phase of bipolar disorder.
Question 4 of 5
A client has been given a prescription to begin using nitroglycerin transdermal medication patches. The nurse instructs the client about this medication administration system and provides which information? Select all that apply.
Correct Answer: B,C
Rationale: Nitroglycerin is a coronary vasodilator used in the management of coronary artery disease. The client is generally advised to apply a new medication patch each morning and leave it in place for 12 to 16 hours as the primary health care provider prescribes. The client needs the medication patch applied daily, not every 7 days, to ensure proper dosing is released as prescribed by the primary health care provider. The client can apply a new medication patch if it becomes dislodged because the dose is released continuously in small amounts through the skin. The client should avoid placing the medication patch in skinfolds or excoriated areas for appropriate absorption.
Question 5 of 5
The nurse is making rounds and observes a client who is unconscious (see fi gure). The nursing assistant has just turned the client from lying on her back. Before raising the side rail, the nurse should:
Correct Answer: C
Rationale: The client is positioned correctly in the side-lying position. The pillows support the client’s joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client’s skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.