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
A client with a history of schizophrenia is prescribed paliperidone (Invega). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Paliperidone can cause hyperprolactinemia, leading to symptoms like galactorrhea.
Question 3 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 4 of 5
The nurse is teaching a client about the use of a metered-dose inhaler with a spacer. Which step should the client perform first?
Correct Answer: A
Rationale: Shaking the inhaler first ensures the medication is properly mixed for effective delivery through the spacer.
Question 5 of 5
The nurse is assessing a client with a suspected anaphylactic reaction. Which of the following interventions is the highest priority?
Correct Answer: A
Rationale: Administering epinephrine is the highest priority in anaphylaxis to reverse airway constriction and hypotension.