NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
Correct Answer: B
Rationale: Jugular vein distension is a sign of tension pneumothorax due to increased intrathoracic pressure compressing the vena cava.
Question 2 of 5
A menopausal woman is taking hormone replacement therapy. The nurse teaches the client that a warning sign for endometrial cancer that needs to be reported is:
Correct Answer: B
Rationale: Vaginal bleeding in a postmenopausal woman on hormone replacement therapy is a warning sign for endometrial cancer and must be reported. Hot flashes, breast tenderness, and mood swings are common side effects, not cancer indicators.
Question 3 of 5
A client with type I diabetes mellitus is scheduled to have surgery. The client has been NPO since midnight. In the morning, the nurse notices the client's daily insulin has not been ordered. The nurse should:
Correct Answer: B
Rationale: Contacting the physician for insulin orders is critical, as NPO status and surgery alter glucose needs, requiring individualized dosing.
Question 4 of 5
A client prescribed albuterol sulfate by inhalation cannot cough up secretions. The nurse should teach the client which action to best help clear the bronchial secretions?
Correct Answer: D
Rationale: The client should take in increased fluids (2000 to 3000 mL/day unless contraindicated) to make secretions less viscous. This may help the client expectorate secretions. This is standard advice given to clients receiving any of the adrenergic bronchodilators, such as albuterol, unless the client has another health problem that could be worsened by increased fluid intake. Additional exercise will not effectively clear bronchial secretions. A dehumidifier will dry secretions. The client would not be advised to take additional medication.
Question 5 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.