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
A client with a history of depression is prescribed venlafaxine (Effexor). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Venlafaxine, an SNRI, can cause hypertension, requiring monitoring.
Question 3 of 5
Your client has a doctor's order for 1200 mLs of intravenous fluid every 8 hours. Your shift began at 8 am and there were 600 mLs remaining in the intravenous fluid bag. How many mLs would you expect to see at 12 noon?
Correct Answer: A
Rationale:
To calculate: 1,200 mL ÷ 8 hours = 150 mL/hr. From 8 AM to 12 noon (4 hours), 4 × 150 = 600 mL infused. Starting with 600 mL, 600 - 600 = 0 mL remaining.
Question 4 of 5
A client with a history of schizophrenia is prescribed risperidone (Risperdal). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Risperidone can cause extrapyramidal symptoms, such as tremors and rigidity, requiring monitoring.
Question 5 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.