NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order should the nurse provide care for this client?
Correct Answer: A,C,D
Rationale: The correct order is: 1) Stop the transfusion to halt the reaction, 2) Keep the vein open with saline to maintain access, 3) Administer antihistamine to manage symptoms, and 4) Send the blood bag to the blood bank for analysis.
Question 2 of 5
The nurse delegates the care of a multiparous client who delivered a viable term neonate vaginally 30 hours ago and is preparing to be discharged to a licensed practical nurse (LPN). The nurse should instruct the LPN to notify the nurse if the client exhibits which of the following?
Correct Answer: A
Rationale: A pulse rate of 100 bpm may indicate postpartum complications like hemorrhage or infection, requiring nurse notification.
Question 3 of 5
A client was admitted to the hospital with a diagnosis of frequent symptomatic premature ventricular contractions (PVCs). After sitting up in a chair for a few minutes, the client reports feeling lightheaded. Which finding should the nurse anticipate on auscultation of the heartbeat?
Correct Answer: B
Rationale: The most accurate means of assessing pulse rhythm is by auscultation of the apical pulse. When a client has PVCs, the rate is irregular and if the radial pulse is taken, a true picture of what is occurring is not obtained. A very slow regular apical pulse indicates bradycardia. A very rapid regular apical pulse indicates tachycardia.
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
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.