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
An Hispanic mother who does not speak English and is very upset brings her child to the clinic with bleeding from the mouth. Which of the following is the most appropriate action by the nurse who does not speak Spanish?
Correct Answer: A
Rationale: Calling an interpreter ensures accurate communication, addressing the mother's distress and obtaining a clear history.
Question 3 of 5
Your client has a doctor's order for 1200 mLs of intravenous fluid every 8 hours. Your shift began at 8 am and there were 600 mLs remaining in the intravenous fluid bag. How many mLs would you expect to see at 12 noon?
Correct Answer: A
Rationale:
To calculate: 1,200 mL ÷ 8 hours = 150 mL/hr. From 8 AM to 12 noon (4 hours), 4 × 150 = 600 mL infused. Starting with 600 mL, 600 - 600 = 0 mL remaining.
Question 4 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 5 of 5
The nurse caring for a client with diabetes realizes that the client has a higher risk of developing cataracts and:
Correct Answer: D
Rationale: Diabetic retinopathy, encompassing both background and proliferative types, is a common complication of diabetes due to chronic hyperglycemia affecting retinal blood vessels.