NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A client with a history of hypothyroidism is admitted with myxedema coma. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: Intravenous levothyroxine is the priority to correct severe hypothyroidism in myxedema coma.
Question 2 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.
Question 3 of 5
The nurse is monitoring for the presence of pitting edema in the prenatal client. The nurse presses the fingertips of the middle and index fingers against the shin in 4 different locations and holds pressure for 2 to 3 seconds. The nurse notes that the indentation is approximately 1-inch deep. The nurse should document that the client has which level of pitting edema?
Correct Answer: D
Rationale: When evaluating the presence of pitting edema, the nurse presses the fingertips of the index and middle fingers against the shin and holds pressure for 2 to 3 seconds. An indentation approximately 1-inch deep would be indicative of +4 edema. A slight indentation would indicate +1 edema. An indentation approximately 1/4-inch deep indicates +2 edema. An indentation approximately 1/2-inch deep indicates +3 edema.
Question 4 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 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.