NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is assessing fetal position in a 32-year-old woman in her eighth month of pregnancy. From the fi gure below, the fetal position can be described as:
Correct Answer: D
Rationale: In right occipital anterior lie, the occiput faces the right anterior segment of the woman’s pelvis. In left occipital transverse lie, the occiput faces the woman’s left hip. In left occipital anterior lie, the occiput faces the left anterior segment of the woman’s pelvis. In right occipital transverse lie, the occiput faces the woman’s right hip.
Question 2 of 5
The primary purpose of root cause analysis is to:
Correct Answer: A
Rationale: Root cause analysis aims to identify underlying process flaws that contributed to an adverse event to prevent recurrence, rather than focusing on individual blame .
Question 3 of 5
A 2-month-old infant is brought to the clinic with a fever of 101°F (38.3°C). What should the nurse instruct the parents to do first?
Correct Answer: C
Rationale: A fever in a 2-month-old is a medical emergency due to the risk of serious bacterial infection. Immediate medical attention is required.
Question 4 of 5
The nurse is monitoring a client diagnosed with hypercalcemia. Which assessment finding indicates a need for follow-up?
Correct Answer: B
Rationale: The client with hypercalcemia is at risk for formation of blood clots. Clotting is more likely to occur in the lower legs, pelvic region, and areas where blood flow is blocked (causing constriction). The nurse should assess for impaired blood flow by measuring calf circumference with a soft tape measure and assess temperature, color, and capillary refill. Decreased capillary refill may be indicative of a clot. The client with hypercalcemia may also exhibit decreased peristalsis, decreased deep tendon reflexes, altered level of consciousness, hypoactive or absent bowel sounds, or increased abdominal circumference as a result of decreased peristalsis.
Question 5 of 5
A client with a history of stroke is prescribed ticlopidine (Ticlid). The nurse should monitor the client for which of the following side effects?
Correct Answer: A
Rationale: Ticlopidine, an antiplatelet medication, increases the risk of bleeding, which the nurse should monitor.