NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A client is being discharged from the hospital after removal of chest tubes that were inserted following thoracic surgery. When providing home care instructions to the client, which client statement indicates a need for further teaching?
Correct Answer: C
Rationale: Upon removal of a chest tube, a dressing is usually placed over the chest tube site. This is maintained in place until the primary health care provider says it may be removed. The client should avoid heavy lifting for the first 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any respiratory difficulty or increased temperature.
Question 2 of 5
A client has been prescribed lansoprazole for 4 weeks. The nurse should monitor the client for relief from which problem?
Correct Answer: B
Rationale: Lansoprazole is a proton pump inhibitor and is classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often referred to as heartburn by clients. The medication does not improve the other symptoms listed.
Question 3 of 5
A client with a history of atrial fibrillation is prescribed digoxin (Lanoxin). The nurse should teach the client to report which of the following symptoms as a potential sign of toxicity?
Correct Answer: B
Rationale: Yellow-green visual halos are a classic sign of digoxin toxicity, indicating the need for immediate medical evaluation.
Question 4 of 5
The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. The nurse is aware that this finding is a major indicator of the development of which of the following conditions?
Correct Answer: C
Rationale: Low arterial oxygen levels unresponsive to high oxygen concentrations are indicative of ARDS, often seen in severe trauma due to lung injury. Pneumonia, shock, and asthma present differently.
Question 5 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.