NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A client has had a left mastectomy with axillary lymph node dissection. The nurse determines that the client understands postoperative restrictions and arm care when the client states the intention to engage in which activity?
Correct Answer: A
Rationale: The client is at risk for edema and infection as a result of lymph node dissection. The client should use a variety of techniques to avoid trauma to the affected arm. Examples include using gloves when working in the garden, an electric razor to shave under the arm, and pot holders when cooking to prevent burns. The client should also avoid activities that increase edema, such as carrying heavy objects or having blood pressures taken on the affected arm.
Question 2 of 5
A postmastectomy client has been found to have an estrogen receptor-positive tumor. The nurse interprets after reading this information in the pathology report that the client will most likely have which common follow-up treatment prescribed?
Correct Answer: C
Rationale: A common treatment for women with estrogen receptor-positive breast tumors is follow-up treatment with tamoxifen. This medication is classified as an antineoplastic agent and competes with estrogen for binding sites in the breast and other tissues. The medication may be administered for years after surgery. The remaining options suggest incorrect treatments.
Question 3 of 5
A client with a history of heart failure is prescribed sacubitril/valsartan (Entresto). The nurse should monitor the client for which of the following side effects?
Correct Answer: A
Rationale: Sacubitril/valsartan can cause hyperkalemia, requiring monitoring of potassium levels.
Question 4 of 5
The CRIES scale is used to:
Correct Answer: D
Rationale: The CRIES scale is a neonatal pain assessment tool used to evaluate pain based on crying, oxygen requirement, vital signs, facial expression, and sleeplessness.
Question 5 of 5
A client with heart failure is prescribed spironolactone (Aldactone). The nurse should monitor for which of the following electrolyte imbalances?
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, increasing the risk of hyperkalemia. Hypokalemia is associated with loop diuretics, and hyponatremia or hypercalcemia are less likely.