NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 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 2 of 5
Which assessment should the nurse complete before beginning the infusion of lipids (fat emulsion) intravenously for a client receiving total parenteral nutrition?
Correct Answer: A
Rationale: Before administering any medication, the nurse assesses for allergies to all of the agent's components. Fat emulsions such as intralipids contain an emulsifying agent made from egg yolks, so clients who are hypersensitive to eggs are at risk for developing hypersensitivity reactions. The remaining options are unrelated to administering lipids.
Question 3 of 5
The nurse is teaching a client with a new diagnosis of gout about dietary modifications. Which of the following foods should the client avoid?
Correct Answer: B
Rationale: Shellfish are high in purines, which can increase uric acid levels and trigger gout attacks.
Question 4 of 5
Which characteristic of carbon monoxide makes it a particularly dangerous gas?
Correct Answer: A
Rationale: Carbon monoxide is dangerous because it is clear , odorless, and tasteless, making it undetectable without specialized equipment, leading to unnoticed exposure and poisoning.
Question 5 of 5
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
Correct Answer: B
Rationale: Jugular vein distension is a sign of tension pneumothorax due to increased intrathoracic pressure compressing the vena cava.