NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
Select the law that is accurately paired with its description in terms of client rights.
Correct Answer: D
Rationale: HIPAA ensures the privacy and security of technological medical information. The PSDA relates to advance directives, not choosing the level of care or mental health coverage . The Mental Health Parity Act addresses insurance coverage, not privacy .
Question 2 of 5
The nurse is assessing a client with suspected diverticulitis. Which finding supports this diagnosis?
Correct Answer: A
Rationale: Left lower quadrant pain is characteristic of diverticulitis, as diverticula commonly form in the sigmoid colon, causing localized inflammation.
Question 3 of 5
The nurse is monitoring a client diagnosed with hypercalcemia. Which assessment finding indicates a need for follow-up?
Correct Answer: B
Rationale: The client with hypercalcemia is at risk for formation of blood clots. Clotting is more likely to occur in the lower legs, pelvic region, and areas where blood flow is blocked (causing constriction). The nurse should assess for impaired blood flow by measuring calf circumference with a soft tape measure and assess temperature, color, and capillary refill. Decreased capillary refill may be indicative of a clot. The client with hypercalcemia may also exhibit decreased peristalsis, decreased deep tendon reflexes, altered level of consciousness, hypoactive or absent bowel sounds, or increased abdominal circumference as a result of decreased peristalsis.
Question 4 of 5
A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that:
Correct Answer: C
Rationale: Fluctuation in the water-seal column with breathing indicates the chest tube is patent and functioning correctly, reflecting intrathoracic pressure changes.
Question 5 of 5
Which assessment should the nurse complete before beginning the infusion of lipids (fat emulsion) intravenously for a client receiving total parenteral nutrition?
Correct Answer: A
Rationale: Before administering any medication, the nurse assesses for allergies to all of the agent's components. Fat emulsions such as intralipids contain an emulsifying agent made from egg yolks, so clients who are hypersensitive to eggs are at risk for developing hypersensitivity reactions. The remaining options are unrelated to administering lipids.