NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
Select the client who is at greatest risk for impaired vascular perfusion.
Correct Answer: C
Rationale: Cigarette smoking is a major risk factor for impaired vascular perfusion due to its effects on endothelial damage and atherosclerosis, significantly increasing the risk of peripheral vascular disease.
Question 2 of 5
A client has been prescribed lansoprazole for 4 weeks. The nurse should monitor the client for relief from which problem?
Correct Answer: B
Rationale: Lansoprazole is a proton pump inhibitor and is classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often referred to as heartburn by clients. The medication does not improve the other symptoms listed.
Question 3 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 4 of 5
Select the risk factor that is accurately paired with its disorder.
Correct Answer: C
Rationale: Hyperkalemia is associated with ketoacidosis, as metabolic acidosis can cause potassium to shift out of cells, elevating serum levels.
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.