NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 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 2 of 5
The nurse observes that a client who has received midazolam (Versed) for local anesthesia is having shallow respirations. The nurse should:
Correct Answer: C
Rationale: Midazolam can cause respiratory depression, so administering oxygen as ordered is the most appropriate initial response.
Question 3 of 5
When teaching a client with bipolar disorder, mania, who has started to take valproic acid (Depakene) about possible side effects of this medication, the nurse should include which of the following in the teaching plan?
Correct Answer: C
Rationale: Valproic acid commonly causes sedation as a side effect, which the client should be aware of to manage daily activities safely.
Question 4 of 5
The nurse is assessing a client with suspected meningitis. Which of the following findings would support this diagnosis? Select all that apply.
Correct Answer: A, B, D
Rationale: Nuchal rigidity, positive Kernig's sign, and photophobia are classic signs of meningitis due to meningeal irritation.
Question 5 of 5
A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that:
Correct Answer: C
Rationale: Fluctuation in the water-seal column with breathing indicates the chest tube is patent and functioning correctly, reflecting intrathoracic pressure changes.