NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 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.
Question 2 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 3 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 4 of 5
The nurse observes that a client who has received midazolam (Versed) for local anesthesia is having shallow respirations. The nurse should:
Correct Answer: C
Rationale: Midazolam can cause respiratory depression, so administering oxygen as ordered is the most appropriate initial response.
Question 5 of 5
The nurse is monitoring for the presence of pitting edema in the prenatal client. The nurse presses the fingertips of the middle and index fingers against the shin in 4 different locations and holds pressure for 2 to 3 seconds. The nurse notes that the indentation is approximately 1-inch deep. The nurse should document that the client has which level of pitting edema?
Correct Answer: D
Rationale: When evaluating the presence of pitting edema, the nurse presses the fingertips of the index and middle fingers against the shin and holds pressure for 2 to 3 seconds. An indentation approximately 1-inch deep would be indicative of +4 edema. A slight indentation would indicate +1 edema. An indentation approximately 1/4-inch deep indicates +2 edema. An indentation approximately 1/2-inch deep indicates +3 edema.