NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A client with a head injury and a feeding tube continuously tries to remove the tube. The nurse contacts the primary health care provider who prescribes the use of restraints. After checking the agency's policy and procedure regarding the use of restraints, the nurse uses which method in restraining the client?
Correct Answer: D
Rationale: Mitten restraints are useful for this client because the client cannot pull against them, creating resistance that could lead to increased intracranial pressure (ICP). Belt and waist restraints prevent the client from getting up or falling out of bed or off a stretcher but do nothing to limit hand movement. Wrist restraints cause resistance.
Question 2 of 5
Which of the following nursing diagnoses is a priority for the family whose child is dying of leukemia?
Correct Answer: D
Rationale: Grieving is the priority nursing diagnosis for a family with a child dying of leukemia, as it addresses their emotional response to impending loss. Other diagnoses may apply but are less immediate.
Question 3 of 5
A client with a history of rheumatoid arthritis is admitted with a flare-up. The nurse should include which of the following in the plan of care?
Correct Answer: A
Rationale: NSAIDs reduce inflammation and pain during rheumatoid arthritis flare-ups.
Question 4 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 5 of 5
The nurse is assessing a client with a suspected anaphylactic reaction. Which of the following interventions is the highest priority?
Correct Answer: A
Rationale: Administering epinephrine is the highest priority in anaphylaxis to reverse airway constriction and hypotension.