NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 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 2 of 5
The nurse is administering a subcutaneous injection of heparin. Which technique ensures safe administration?
Correct Answer: D
Rationale: Pinching the skin creates a fold for subcutaneous injection, ensuring heparin is delivered into the correct tissue layer without damaging underlying structures.
Question 3 of 5
A client’s arterial blood gas values are as follows: These findings indicate which of the following acidbase imbalances?
Correct Answer: A
Rationale: The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal, but the HCO3 level is decreased. These findings indicate that the client is in metabolic acidosis.
Question 4 of 5
A client with a history of depression is prescribed venlafaxine (Effexor). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Venlafaxine, an SNRI, can cause hypertension, requiring monitoring.
Question 5 of 5
The nurse is teaching a client with hypertension about lifestyle modifications. Which of the following should the nurse include? Select all that apply.
Correct Answer: A, B, D, E
Rationale: Reducing sodium, regular aerobic exercise, maintaining healthy weight, and stress management help control hypertension. Moderate alcohol is acceptable, not total avoidance.