NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a child with diabetes mellitus at camp. The child is irritable and has a headache. Which of the following should the nurse do first?
Correct Answer: C
Rationale: Checking the blood glucose level determines whether the symptoms are due to hypo- or hyperglycemia, guiding treatment.
Question 2 of 5
Intravenous 5% albumin is prescribed for a client with burns of the anterior chest and both legs. The nurse contacts the primary health care provider before administering the human albumin if which are noted in the client's record? Select all that apply.
Correct Answer: A,D
Rationale: Five percent albumin is classified as a blood derivative and is contraindicated in severe anemia, cardiac failure, history of allergic reaction, renal insufficiency, and when no albumin deficiency is present. It is used with caution in clients with low cardiac reserve, pulmonary disease, or hepatic or renal failure.
Question 3 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 heals by secondary intention, as the wound is left open to heal from the base up due to infection.
Question 4 of 5
A client is being discharged from the hospital after removal of chest tubes that were inserted following thoracic surgery. When providing home care instructions to the client, which client statement indicates a need for further teaching?
Correct Answer: C
Rationale: Upon removal of a chest tube, a dressing is usually placed over the chest tube site. This is maintained in place until the primary health care provider says it may be removed. The client should avoid heavy lifting for the first 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any respiratory difficulty or increased temperature.
Question 5 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.