NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse assesses a client who is receiving a tube feeding. Which of the following situations would require prompt intervention from the nurse?
Correct Answer: B
Rationale: A feeding hanging for 8 hours poses an infection risk due to bacterial growth, requiring prompt intervention.
Question 2 of 5
The nurse is preparing to give an I.M. injection. Which of the following sites has the least amount of blood vessels and major nerves located in the area?
Correct Answer: C
Rationale: The vastus lateralis has fewer blood vessels and nerves compared to the deltoid, dorsogluteal, or triceps, making it a safer site for I.M. injections.
Question 3 of 5
A client has had a left mastectomy with axillary lymph node dissection. The nurse determines that the client understands postoperative restrictions and arm care when the client states the intention to engage in which activity?
Correct Answer: A
Rationale: The client is at risk for edema and infection as a result of lymph node dissection. The client should use a variety of techniques to avoid trauma to the affected arm. Examples include using gloves when working in the garden, an electric razor to shave under the arm, and pot holders when cooking to prevent burns. The client should also avoid activities that increase edema, such as carrying heavy objects or having blood pressures taken on the affected arm.
Question 4 of 5
When planning the care for a client diagnosed with hepatitis A, which of the following nursing interventions should the nurse expect to include? Select all that apply.
Correct Answer: B,D,E
Rationale: Hepatitis A care includes relieving nausea and vomiting, encouraging small meals to improve nutrition, and planning rest periods due to fatigue. Exercise and pain medication are not typically needed.
Question 5 of 5
A client with a history of asthma is admitted with an exacerbation. The nurse should administer which of the following medications as prescribed? Select all that apply.
Correct Answer: A, B, C
Rationale: Albuterol, ipratropium, and prednisone treat acute asthma exacerbations by relieving bronchospasm and inflammation.