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
Under the policy for valuables, the nurse documents the description on an envelope with the client, the client and nurse sign the envelope, and the valuables envelope is locked in the safe. The other options increase the risk of loss or damage to the client's valuables.
Correct Answer: A
Rationale: This procedure ensures the security of the client's valuables, reducing the risk of loss or theft.
Question 3 of 5
A client prescribed albuterol sulfate by inhalation cannot cough up secretions. The nurse should teach the client which action to best help clear the bronchial secretions?
Correct Answer: D
Rationale: The client should take in increased fluids (2000 to 3000 mL/day unless contraindicated) to make secretions less viscous. This may help the client expectorate secretions. This is standard advice given to clients receiving any of the adrenergic bronchodilators, such as albuterol, unless the client has another health problem that could be worsened by increased fluid intake. Additional exercise will not effectively clear bronchial secretions. A dehumidifier will dry secretions. The client would not be advised to take additional medication.
Question 4 of 5
You are caring for an infant who is just about 12 months old. Which assessment data is normal for the infant at this age?
Correct Answer: B
Rationale: By 12 months, a healthy infant typically triples their birth weight, making option B correct. Doubling birth weight usually occurs by 6 months. Option C (60 mL/kg) is not a standard measure for assessing normal infant development, and option D (¼ inch growth in a month) is not necessarily indicative of normal growth without further context.
Question 5 of 5
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
Correct Answer: B
Rationale: Jugular vein distension is a sign of tension pneumothorax due to increased intrathoracic pressure compressing the vena cava.