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
A client with a history of heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which of the following electrolyte imbalances?
Correct Answer: A
Rationale: Furosemide causes potassium loss, leading to hypokalemia, which requires monitoring.
Question 3 of 5
Which prescribed procedure should the nurse withhold until a comatose client is properly intubated?
Correct Answer: A
Rationale: Intubation should always precede gastric feeding to prevent pulmonary aspiration. The remaining options identify procedures that can be initiated before intubation of the client.
Question 4 of 5
The nurse is monitoring a client diagnosed with hypercalcemia. Which assessment finding indicates a need for follow-up?
Correct Answer: B
Rationale: The client with hypercalcemia is at risk for formation of blood clots. Clotting is more likely to occur in the lower legs, pelvic region, and areas where blood flow is blocked (causing constriction). The nurse should assess for impaired blood flow by measuring calf circumference with a soft tape measure and assess temperature, color, and capillary refill. Decreased capillary refill may be indicative of a clot. The client with hypercalcemia may also exhibit decreased peristalsis, decreased deep tendon reflexes, altered level of consciousness, hypoactive or absent bowel sounds, or increased abdominal circumference as a result of decreased peristalsis.
Question 5 of 5
While preparing to provide neonatal care instructions to a primiparous client who delivered a term neonate 24 hours ago, which of the following should the nurse include in the client's teaching plan?
Correct Answer: C
Rationale: Milia are benign and disappear spontaneously, requiring no treatment, and should be included in teaching.