NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is making rounds and observes a client who is unconscious (see fi gure). The nursing assistant has just turned the client from lying on her back. Before raising the side rail, the nurse should:
Correct Answer: C
Rationale: The client is positioned correctly in the side-lying position. The pillows support the client’s joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client’s skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.
Question 2 of 5
When assessing for signs of a blood transfusion reaction in a client with dark skin, the nurse should assess for which of the following?
Correct Answer: B
Rationale: Diaphoresis is a visible sign of a transfusion reaction, detectable regardless of skin tone, indicating an acute response.
Question 3 of 5
The nurse is caring for a client with a tracheostomy. Which action is essential to maintain airway patency?
Correct Answer: A
Rationale: Suctioning as needed removes secretions, maintaining tracheostomy patency and preventing airway obstruction.
Question 4 of 5
A client diagnosed with acute kidney injury has an elevated blood urea nitrogen (BUN) and is experiencing difficulty remembering information. Which interventions should the nurse implement when communicating with this client? Select all that apply.
Correct Answer: A,B,C
Rationale: The client with acute kidney injury may have difficulty remembering information and instructions because of anxiety and the increased level of the BUN. The nurse should avoid giving lengthy explanations about procedures because this information may not be remembered by the client and could increase client anxiety. Communications should be clear, simple, and understandable. The family should be included whenever possible. Using several methods for teaching can be overwhelming for the client. The nurse should assess the client's learning needs and select a method that will facilitate learning.
Question 5 of 5
Your client has a doctor's order for 1200 mLs of intravenous fluid every 8 hours. Your shift began at 8 am and there were 600 mLs remaining in the intravenous fluid bag. How many mLs would you expect to see at 12 noon?
Correct Answer: A
Rationale:
To calculate: 1,200 mL ÷ 8 hours = 150 mL/hr. From 8 AM to 12 noon (4 hours), 4 × 150 = 600 mL infused. Starting with 600 mL, 600 - 600 = 0 mL remaining.