NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of peripheral artery disease. Which of the following interventions is most appropriate?
Correct Answer: D
Rationale: Regular walking promotes collateral circulation in peripheral artery disease, improving blood flow.
Question 2 of 5
The nurse is preparing to give an I.M. injection. Which of the following sites has the least amount of blood vessels and major nerves located in the area?
Correct Answer: C
Rationale: The vastus lateralis has fewer blood vessels and nerves compared to the deltoid, dorsogluteal, or triceps, making it a safer site for I.M. injections.
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
A client with a history of heart failure is prescribed sacubitril/valsartan (Entresto). The nurse should monitor the client for which of the following side effects?
Correct Answer: A
Rationale: Sacubitril/valsartan can cause hyperkalemia, requiring monitoring of potassium levels.
Question 5 of 5
A client has had a left mastectomy with axillary lymph node dissection. The nurse determines that the client understands postoperative restrictions and arm care when the client states the intention to engage in which activity?
Correct Answer: A
Rationale: The client is at risk for edema and infection as a result of lymph node dissection. The client should use a variety of techniques to avoid trauma to the affected arm. Examples include using gloves when working in the garden, an electric razor to shave under the arm, and pot holders when cooking to prevent burns. The client should also avoid activities that increase edema, such as carrying heavy objects or having blood pressures taken on the affected arm.