NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that:
Correct Answer: C
Rationale: Fluctuation in the water-seal column with breathing indicates the chest tube is patent and functioning correctly, reflecting intrathoracic pressure changes.
Question 2 of 5
The nurse is teaching a client about warfarin (Coumadin) therapy. Which statement indicates the client understands the teaching?
Correct Answer: B
Rationale: Warfarin increases bleeding risk, so reporting bruising or bleeding is critical to monitor for complications like hemorrhage.
Question 3 of 5
Which of these stress management techniques employs deep focused breathing, movement and meditation?
Correct Answer: B
Rationale: Tai Chi combines deep breathing, slow movements, and meditation, making it an effective stress management technique.
Question 4 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 5 of 5
After a child returns from the postanesthesia care unit after surgery, which of the following should the nurse assess first?
Correct Answer: B
Rationale: Assessing pain first ensures the child's comfort and guides further care, as pain can affect recovery and other assessments.