NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is monitoring for the presence of pitting edema in the prenatal client. The nurse presses the fingertips of the middle and index fingers against the shin in 4 different locations and holds pressure for 2 to 3 seconds. The nurse notes that the indentation is approximately 1-inch deep. The nurse should document that the client has which level of pitting edema?
Correct Answer: D
Rationale: When evaluating the presence of pitting edema, the nurse presses the fingertips of the index and middle fingers against the shin and holds pressure for 2 to 3 seconds. An indentation approximately 1-inch deep would be indicative of +4 edema. A slight indentation would indicate +1 edema. An indentation approximately 1/4-inch deep indicates +2 edema. An indentation approximately 1/2-inch deep indicates +3 edema.
Question 2 of 5
The nurse observes that a client who has received midazolam (Versed) for local anesthesia is having shallow respirations. The nurse should:
Correct Answer: C
Rationale: Midazolam can cause respiratory depression, so administering oxygen as ordered is the most appropriate initial response.
Question 3 of 5
A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that:
Correct Answer: C
Rationale: Fluctuation in the water-seal column with breathing indicates the chest tube is patent and functioning correctly, reflecting intrathoracic pressure changes.
Question 4 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.
Question 5 of 5
To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which of the following positions in bed several times a day?
Correct Answer: A
Rationale: The prone position promotes hip extension, preventing flexion deformities common in rheumatoid arthritis.