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
A client is to receive 2 g of metronidazole (Flagyl) orally in a single dose. The medication is available in 500-mg tablets. How many tablets should the nurse administer?
Correct Answer: 4 tablets.
Rationale: 2 g equals 2000 mg. Dividing 2000 mg by 500 mg per tablet results in 4 tablets.
Question 3 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 4 of 5
A multiparous client 48 hours postpartum who is breast-feeding tells the nurse, 'I'm having a lot of cramping. This didn't happen when I nursed my first baby,' which of the following would be the nurse's best response?
Correct Answer: D
Rationale: Breast-feeding stimulates oxytocin release, causing uterine contractions and cramping, which is normal and often more noticeable in multiparous women.
Question 5 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.