NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A client with a history of atrial fibrillation is prescribed digoxin (Lanoxin). The nurse should teach the client to report which of the following symptoms as a potential sign of toxicity?
Correct Answer: B
Rationale: Yellow-green visual halos are a classic sign of digoxin toxicity, indicating the need for immediate medical evaluation.
Question 2 of 5
A client with a diagnosis of rheumatoid arthritis is prescribed tofacitinib (Xeljanz). The nurse should monitor the client for which of the following side effects?
Correct Answer: A
Rationale:
Tofacitinib, a JAK inhibitor, increases the risk of infections due to immune suppression.
Question 3 of 5
The nurse caring for a client with diabetes realizes that the client has a higher risk of developing cataracts and:
Correct Answer: D
Rationale: Diabetic retinopathy, encompassing both background and proliferative types, is a common complication of diabetes due to chronic hyperglycemia affecting retinal blood vessels.
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
The nurse is caring for a client with a history of burns. Which of the following interventions should be included in the plan of care?
Correct Answer: A
Rationale: Monitoring for infection is critical in burns due to high risk of sepsis.