NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
After a child returns from the postanesthesia care unit after surgery, which of the following should the nurse assess first?
Correct Answer: B
Rationale: Assessing pain first ensures the child's comfort and guides further care, as pain can affect recovery and other assessments.
Question 2 of 5
A client diagnosed with acute kidney injury has an elevated blood urea nitrogen (BUN) and is experiencing difficulty remembering information. Which interventions should the nurse implement when communicating with this client? Select all that apply.
Correct Answer: A,B,C
Rationale: The client with acute kidney injury may have difficulty remembering information and instructions because of anxiety and the increased level of the BUN. The nurse should avoid giving lengthy explanations about procedures because this information may not be remembered by the client and could increase client anxiety. Communications should be clear, simple, and understandable. The family should be included whenever possible. Using several methods for teaching can be overwhelming for the client. The nurse should assess the client's learning needs and select a method that will facilitate learning.
Question 3 of 5
Under the policy for valuables, the nurse documents the description on an envelope with the client, the client and nurse sign the envelope, and the valuables envelope is locked in the safe. The other options increase the risk of loss or damage to the client's valuables.
Correct Answer: A
Rationale: This procedure ensures the security of the client's valuables, reducing the risk of loss or theft.
Question 4 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 5 of 5
A client’s arterial blood gas values are as follows: These findings indicate which of the following acidbase imbalances?
Correct Answer: A
Rationale: The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal, but the HCO3 level is decreased. These findings indicate that the client is in metabolic acidosis.