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
A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order should the nurse provide care for this client?
Order the Items
Source Container
Correct Answer: A,C,D
Rationale: The correct order is: 1) Stop the transfusion to halt the reaction, 2) Keep the vein open with saline to maintain access, 3) Administer antihistamine to manage symptoms, and 4) Send the blood bag to the blood bank for analysis.
Question 3 of 5
The nurse is developing a plan of care for a client diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse should document which goals for the client in the plan of care? Select all that apply.
Correct Answer: A,D
Rationale: A common, life-threatening opportunistic infection that occurs in clients with AIDS is Pneumocystis jiroveci pneumonia. Its symptoms include fever, exertional dyspnea, and nonproductive cough. The absence of respiratory distress and that of a fever are two of the goals that the nurse sets as priorities. The remaining options are not specifically related to AIDS.
Question 4 of 5
Your pregnant client has a new order for a medication. What principle should you apply to this new medication?
Correct Answer: A
Rationale: FDA pregnancy categories C, D, and X indicate potential or known risks to the fetus, making them contraindicated unless benefits outweigh risks.
Question 5 of 5
You are caring for a client who has been taking illicit amphetamines and states that they continue to use this illicit drug because they 'suffer and feel lousy' when they try to stop taking it. Which nursing diagnosis is the most appropriate for this client?
Correct Answer: D
Rationale: The client's symptoms of feeling 'lousy' when stopping the drug indicate physical dependence, as the body has adapted to the presence of amphetamines, leading to withdrawal symptoms upon cessation.