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
The nurse is teaching a client with a new diagnosis of type 1 diabetes about insulin administration. Which of the following instructions should be included?
Correct Answer: A, D
Rationale: Rotating injection sites prevents lipodystrophy, and room-temperature insulin reduces injection discomfort.
Question 3 of 5
An Hispanic mother who does not speak English and is very upset brings her child to the clinic with bleeding from the mouth. Which of the following is the most appropriate action by the nurse who does not speak Spanish?
Correct Answer: A
Rationale: Calling an interpreter ensures accurate communication, addressing the mother's distress and obtaining a clear history.
Question 4 of 5
The mother of an infant with iron deficiency anemia asks the nurse what she could have done to prevent the anemia. The nurse should teach the mother that it is helpful to introduce solid foods into the infant's diet at age:
Correct Answer: B
Rationale: Introducing solids at 5-6 months provides iron-rich foods, helping prevent iron deficiency anemia.
Question 5 of 5
The nurse is preparing a client for a colonoscopy. Which instruction is most important?
Correct Answer: B
Rationale: A clear liquid diet the day before ensures the colon is clear for accurate visualization during the colonoscopy.