NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A client has had an incisional cholecystectomy. Which of the following nursing interventions has the highest priority in postoperative care for this client?
Correct Answer: A
Rationale: Incentive spirometry prevents postoperative pulmonary complications, a significant risk after abdominal surgery, by promoting lung expansion.
Question 2 of 5
A nurse is caring for a toddler who is assessed as having hypertonicity, delayed fine motor skills, and poor control of coordinated motion. This is indicative of what cerebral palsy (CP) classification? Select all that apply.
Correct Answer: C,E
Rationale: Spastic cerebral palsy is characterized by hypertonicity and poor coordination. Abnormal involuntary or wormlike movements suggest dyskinetic CP, and gross motor impairment is not specified here.
Question 3 of 5
A client with a history of alcohol abuse is admitted with confusion and tremors. The nurse should prepare to administer which medication?
Correct Answer: A
Rationale: Thiamine is administered to prevent Wernicke's encephalopathy, a neurological complication of alcohol withdrawal associated with confusion and tremors.
Question 4 of 5
The nurse is caring for a client with a history of hyperlipidemia who is prescribed atorvastatin (Lipitor). Which of the following laboratory tests should the nurse monitor?
Correct Answer: B
Rationale: Atorvastatin can cause hepatotoxicity, requiring regular monitoring of liver function tests.
Question 5 of 5
The nurse is caring for a client with a history of heart failure who is receiving digoxin (Lanoxin). Which of the following findings would indicate digoxin toxicity?
Correct Answer: A
Rationale: Blurred vision is a classic sign of digoxin toxicity, along with nausea, confusion, and arrhythmias, due to excessive drug levels affecting the nervous system.