NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is performing a physical assessment on a client with rheumatoid arthritis. The nurse assesses the client's hands and notes which characteristic deformities? Refer to the figure.
Correct Answer: A
Rationale: Ulnar drift occurs when synovitis stretches and damages the tendons, and eventually the tendons become shortened and fixed. This damage causes subluxation (drift) of the joints. All of the conditions that are identified in the options can occur in rheumatoid arthritis; however, the figure pictures ulnar drift.
Question 2 of 5
The nurse is planning to complete the following assessments during the last half hour of the shift. Which of the following assessments has the highest priority and should be accomplished first?
Correct Answer: A
Rationale: The infant with transient tachypnea of the newborn (TTN) and a respiratory rate of 60 breaths/minute indicates potential respiratory distress, which is a life-threatening condition requiring immediate assessment.
Question 3 of 5
Under the policy for valuables, the nurse documents the description on an envelope with the client, the client and nurse sign the envelope, and the valuables envelope is locked in the safe. The other options increase the risk of loss or damage to the client's valuables.
Correct Answer: A
Rationale: This procedure ensures the security of the client's valuables, reducing the risk of loss or theft.
Question 4 of 5
A client with a history of depression is prescribed venlafaxine (Effexor). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Venlafaxine, an SNRI, can cause hypertension, requiring monitoring.
Question 5 of 5
Long-term administration of gentamicin sulfate (Garamycin) to a client has been discontinued. The nurse should assess which of the following?
Correct Answer: C
Rationale: Gentamicin can cause ototoxicity, affecting the vestibular system, so a vestibular check in 3 to 4 weeks is necessary to assess for balance issues. The other options are not directly related to gentamicin's side effects.