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
Your family, as the client, now has four children and the parents do not want any other children at this time. The mother has a history of deep vein thrombosis and cigarette smoking; and both parents have a history of the lack of adherence to medical regimens. Which form of Contraception would you recommend for this couple?
Correct Answer: D
Rationale: Given the mother's history of deep vein thrombosis, hormonal contraceptives like the transdermal patch or vaginal ring are contraindicated due to increased clotting risk. A diaphragm may be unreliable due to non-adherence. Non-hormonal options like an IUD or permanent sterilization may be more suitable, but none of the listed options are ideal.
Question 3 of 5
A client with a history of type 1 diabetes mellitus is prescribed insulin glargine (Lantus). The nurse should explain that this insulin:
Correct Answer: B
Rationale: Insulin glargine provides a steady basal insulin level over 24 hours, used for long-term glucose control.
Question 4 of 5
A client with a history of Addison's disease is prescribed hydrocortisone (Cortef). The nurse should instruct the client to:
Correct Answer: C
Rationale: Hydrocortisone suppresses immunity, so reporting signs of infection is critical in Addison's disease.
Question 5 of 5
The nurse is teaching a client about warfarin (Coumadin) therapy. Which statement indicates the client understands the teaching?
Correct Answer: B
Rationale: Warfarin increases bleeding risk, so reporting bruising or bleeding is critical to monitor for complications like hemorrhage.