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
Your client had a ruptured appendix and peritonitis. What type of healing would be most likely for this client?
Correct Answer: A
Rationale: A ruptured appendix with peritonitis typically results in a wound that heals by secondary intention, where the wound is left open to heal from the base up due to infection.
Question 3 of 5
A client prescribed albuterol sulfate by inhalation cannot cough up secretions. The nurse should teach the client which action to best help clear the bronchial secretions?
Correct Answer: D
Rationale: The client should take in increased fluids (2000 to 3000 mL/day unless contraindicated) to make secretions less viscous. This may help the client expectorate secretions. This is standard advice given to clients receiving any of the adrenergic bronchodilators, such as albuterol, unless the client has another health problem that could be worsened by increased fluid intake. Additional exercise will not effectively clear bronchial secretions. A dehumidifier will dry secretions. The client would not be advised to take additional medication.
Question 4 of 5
When planning the care for a client diagnosed with hepatitis A, which of the following nursing interventions should the nurse expect to include? Select all that apply.
Correct Answer: B,D,E
Rationale: Hepatitis A care includes relieving nausea and vomiting, encouraging small meals to improve nutrition, and planning rest periods due to fatigue. Exercise and pain medication are not typically needed.
Question 5 of 5
The nurse is preparing to give an I.M. injection. Which of the following sites has the least amount of blood vessels and major nerves located in the area?
Correct Answer: C
Rationale: The vastus lateralis has fewer blood vessels and nerves compared to the deltoid, dorsogluteal, or triceps, making it a safer site for I.M. injections.