NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A client diagnosed with acute kidney injury has an elevated blood urea nitrogen (BUN) and is experiencing difficulty remembering information. Which interventions should the nurse implement when communicating with this client? Select all that apply.
Correct Answer: A,B,C
Rationale: The client with acute kidney injury may have difficulty remembering information and instructions because of anxiety and the increased level of the BUN. The nurse should avoid giving lengthy explanations about procedures because this information may not be remembered by the client and could increase client anxiety. Communications should be clear, simple, and understandable. The family should be included whenever possible. Using several methods for teaching can be overwhelming for the client. The nurse should assess the client's learning needs and select a method that will facilitate learning.
Question 2 of 5
A client with a history of heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which of the following electrolyte imbalances?
Correct Answer: A
Rationale: Furosemide causes potassium loss, leading to hypokalemia, which requires monitoring.
Question 3 of 5
The nurse is preparing to teach the parents of a child diagnosed with anemia about the dietary sources of iron that are easy for the body to absorb. Which food items should the nurse include in the teaching plan as the best source of absorbable iron? Select all that apply.
Correct Answer: A,C
Rationale: Dietary sources of iron that are easy for the body to absorb include meat, poultry, and fish. Vegetables, fruits, cereals, and breads are also dietary sources of iron, but they are harder for the body to absorb.
Question 4 of 5
The nurse delegates the care of a multiparous client who delivered a viable term neonate vaginally 30 hours ago and is preparing to be discharged to a licensed practical nurse (LPN). The nurse should instruct the LPN to notify the nurse if the client exhibits which of the following?
Correct Answer: A
Rationale: A pulse rate of 100 bpm may indicate postpartum complications like hemorrhage or infection, requiring nurse notification.
Question 5 of 5
The nurse is monitoring a client diagnosed with hypercalcemia. Which assessment finding indicates a need for follow-up?
Correct Answer: B
Rationale: The client with hypercalcemia is at risk for formation of blood clots. Clotting is more likely to occur in the lower legs, pelvic region, and areas where blood flow is blocked (causing constriction). The nurse should assess for impaired blood flow by measuring calf circumference with a soft tape measure and assess temperature, color, and capillary refill. Decreased capillary refill may be indicative of a clot. The client with hypercalcemia may also exhibit decreased peristalsis, decreased deep tendon reflexes, altered level of consciousness, hypoactive or absent bowel sounds, or increased abdominal circumference as a result of decreased peristalsis.