NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is assessing a client with suspected hypovolemia. Which of the following findings would support this diagnosis? Select all that apply.
Correct Answer: A, B, C, D
Rationale: Hypovolemia presents with tachycardia, hypotension, dry mucous membranes, and decreased urine output due to fluid loss.
Question 2 of 5
The nurse receives a specimen of clear, watery sputum from a client. Which of the following actions is most appropriate for the nurse to take?
Correct Answer: A
Rationale: Clear, watery sputum may indicate a condition like pulmonary edema, requiring prompt laboratory analysis for accurate diagnosis.
Question 3 of 5
A client is being discharged after undergoing a transurethral resection of the prostate (TURP). The nurse teaches the client to expect which variation in normal urine color for several days after the procedure?
Correct Answer: B
Rationale: The client should expect that the urine will be pink-tinged for several days after this procedure. Dark red urine may be present initially, especially with inadequate bladder irrigation, and if it occurs, it must be corrected. Clear urine is not expected after surgery; cloudy urine could indicate an infection.
Question 4 of 5
A client with a head injury and a feeding tube continuously tries to remove the tube. The nurse contacts the primary health care provider who prescribes the use of restraints. After checking the agency's policy and procedure regarding the use of restraints, the nurse uses which method in restraining the client?
Correct Answer: D
Rationale: Mitten restraints are useful for this client because the client cannot pull against them, creating resistance that could lead to increased intracranial pressure (ICP). Belt and waist restraints prevent the client from getting up or falling out of bed or off a stretcher but do nothing to limit hand movement. Wrist restraints cause resistance.
Question 5 of 5
A client is admitted to the hospital in myasthenic crisis. The nurse should ask the client about which precipitating factor for this event?
Correct Answer: B
Rationale: Myasthenic crisis is often caused by undermedication and responds to the administration of cholinergic medications such as neostigmine and pyridostigmine. Increased sleep and change in diet are not precipitating factors. However, overexertion and overeating could possibly trigger myasthenic crisis. Cholinergic crisis is caused by excess medication and responds to withholding of medications.