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 with a history of Addison's disease is prescribed hydrocortisone (Cortef). The nurse should instruct the client to:
Correct Answer: C
Rationale: Hydrocortisone suppresses immunity, so reporting signs of infection is critical in Addison's disease.
Question 3 of 5
A client with a history of schizophrenia is prescribed risperidone (Risperdal). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Risperidone can cause extrapyramidal symptoms, such as tremors and rigidity, requiring monitoring.
Question 4 of 5
A client previously well controlled with glyburide has recently begun reporting fasting blood glucose to be 180 to 200 mg/dL (10.28-11.42 mmol/L). Which medication, noted in the client's record, may be contributing to the elevated blood glucose level?
Correct Answer: A
Rationale: Corticosteroids, thiazide diuretics, and lithium may decrease the effect of glyburide, causing hyperglycemia. All the other options may increase the effect of glyburide, leading to hypoglycemia.
Question 5 of 5
A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown below. The nurse is assessing the neonate and determines that the mask:
Correct Answer: B
Rationale: An oxygen mask covering the eyes is too large, potentially obstructing vision and causing discomfort, requiring adjustment.