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 client had a ruptured appendix and peritonitis. What type of healing would be most likely for this client?
Correct Answer: A
Rationale: A ruptured appendix with peritonitis heals by secondary intention, as the wound is left open to heal from the base up due to infection.
Question 3 of 5
A client has a prescription to take magnesium citrate to prevent constipation after upper and lower gastrointestinal (GI) barium studies. The nurse tells the client that which is the best way to take this medication?
Correct Answer: D
Rationale: Magnesium citrate is available as an oral solution. It is commonly used as a laxative after certain studies of the GI tract. It should be served chilled and taken with a full glass of water. It should not be allowed to stand for prolonged periods. Allowing the medication to stand would reduce the carbonation and make the solution even less palatable. The remaining options are incorrect.
Question 4 of 5
A client comes into the emergency department with extreme fatigue. He is malnourished and laboratory tests reveal that he is severely anemic. The nurse should specifically ask the client about his intake of food high in which of the following nutrition:
Correct Answer: B
Rationale: Severe anemia is often due to deficiencies in iron, folate, vitamin B12, or copper, which are essential for red blood cell production. Other vitamins listed are less directly related to anemia.
Question 5 of 5
The nurse receives a specimen of clear, watery sputum from a client. Which of the following actions is most appropriate for the nurse to take?
Correct Answer: A
Rationale: Clear, watery sputum may indicate a condition like pulmonary edema, requiring prompt laboratory analysis for accurate diagnosis.