NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A nurse is administering I.V. fluids to a dehydrated client. When administering an I.V. solution of 3% sodium chloride, what should the nurse do? Select all that apply.
Correct Answer: A,B,C
Rationale: 3% sodium chloride is hypertonic and requires monitoring of intake/output, jugular veins for fluid overload, and neurologic status for hypernatremia effects. Forcing fluids or catheterization is not indicated.
Question 2 of 5
A nurse is caring for a toddler who is assessed as having hypertonicity, delayed fine motor skills, and poor control of coordinated motion. This is indicative of what cerebral palsy (CP) classification? Select all that apply.
Correct Answer: C,E
Rationale: Spastic cerebral palsy is characterized by hypertonicity and poor coordination. Abnormal involuntary or wormlike movements suggest dyskinetic CP, and gross motor impairment is not specified here.
Question 3 of 5
A client with heart failure is prescribed spironolactone (Aldactone). The nurse should monitor for which of the following electrolyte imbalances?
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, increasing the risk of hyperkalemia. Hypokalemia is associated with loop diuretics, and hyponatremia or hypercalcemia are less likely.
Question 4 of 5
A client is preparing for discharge 10 days after a radical vulvectomy. The nurse determines that the client has the best understanding of the measures to prevent complications when the client expresses plans to engage in which activity after discharge?
Correct Answer: A
Rationale: The client should resume activity slowly, and walking is a beneficial activity. The client should know to rest when fatigue occurs. Activities to be avoided include driving, heavy housework, wearing tight clothing, crossing the legs, and prolonged standing or sitting. Sexual activity is usually prohibited for 4 to 6 weeks after surgery.
Question 5 of 5
A client with a history of heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which of the following electrolyte imbalances?
Correct Answer: A
Rationale: Furosemide causes potassium loss, leading to hypokalemia, which requires monitoring.