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 nurse who organizes and establishes a political action committee (PAC) in their local community to address issues relating to the accessibility and affordability of healthcare resources in the community is serving in which capacity and role of the registered nurse?
Correct Answer: A
Rationale: By organizing a PAC to address healthcare accessibility and affordability, the nurse is acting as a client advocate . This role involves promoting the health and well-being of clients and communities by addressing systemic issues, such as access to care, through community and political engagement.
Question 3 of 5
A client was admitted to the hospital with a diagnosis of frequent symptomatic premature ventricular contractions (PVCs). After sitting up in a chair for a few minutes, the client reports feeling lightheaded. Which finding should the nurse anticipate on auscultation of the heartbeat?
Correct Answer: B
Rationale: The most accurate means of assessing pulse rhythm is by auscultation of the apical pulse. When a client has PVCs, the rate is irregular and if the radial pulse is taken, a true picture of what is occurring is not obtained. A very slow regular apical pulse indicates bradycardia. A very rapid regular apical pulse indicates tachycardia.
Question 4 of 5
When assessing a dark-skinned client for cyanosis, the nurse should examine which of the following?
Correct Answer: C
Rationale: The oral mucous membranes are the most reliable site for assessing cyanosis in dark-skinned clients, as they show color changes more clearly.
Question 5 of 5
The nurse observes that a client who has received midazolam (Versed) for local anesthesia is having shallow respirations. The nurse should:
Correct Answer: C
Rationale: Midazolam can cause respiratory depression, so administering oxygen as ordered is the most appropriate initial response.