NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A client with a history of depression is prescribed venlafaxine (Effexor). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Venlafaxine, an SNRI, can cause hypertension, requiring monitoring.
Question 2 of 5
A multigravid client is scheduled for a percutaneous umbilical blood sampling procedure. The nurse instructs the client that this procedure is useful for diagnosing which of the following?
Correct Answer: C
Rationale: Percutaneous umbilical blood sampling is used to diagnose fetal conditions like Rh disease by directly sampling fetal blood for analysis.
Question 3 of 5
The nurse is making rounds and observes a client who is unconscious (see fi gure). The nursing assistant has just turned the client from lying on her back. Before raising the side rail, the nurse should:
Correct Answer: C
Rationale: The client is positioned correctly in the side-lying position. The pillows support the client’s joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client’s skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.
Question 4 of 5
The nurse is administering a subcutaneous injection of heparin. Which technique ensures safe administration?
Correct Answer: D
Rationale: Pinching the skin creates a fold for subcutaneous injection, ensuring heparin is delivered into the correct tissue layer without damaging underlying structures.
Question 5 of 5
Which assessment should the nurse complete before beginning the infusion of lipids (fat emulsion) intravenously for a client receiving total parenteral nutrition?
Correct Answer: A
Rationale: Before administering any medication, the nurse assesses for allergies to all of the agent's components. Fat emulsions such as intralipids contain an emulsifying agent made from egg yolks, so clients who are hypersensitive to eggs are at risk for developing hypersensitivity reactions. The remaining options are unrelated to administering lipids.