NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 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 2 of 5
The nurse is caring for a client with a history of peripheral artery disease. Which of the following interventions is most appropriate?
Correct Answer: D
Rationale: Regular walking promotes collateral circulation in peripheral artery disease, improving blood flow.
Question 3 of 5
A client has had a left mastectomy with axillary lymph node dissection. The nurse determines that the client understands postoperative restrictions and arm care when the client states the intention to engage in which activity?
Correct Answer: A
Rationale: The client is at risk for edema and infection as a result of lymph node dissection. The client should use a variety of techniques to avoid trauma to the affected arm. Examples include using gloves when working in the garden, an electric razor to shave under the arm, and pot holders when cooking to prevent burns. The client should also avoid activities that increase edema, such as carrying heavy objects or having blood pressures taken on the affected arm.
Question 4 of 5
The nurse is assessing a client suspected of having a rib fracture. Which typical signs/symptoms should the nurse observe for?
Correct Answer: D
Rationale: The client with fractured ribs typically has pain over the fracture site with inspiration and to palpation. Respirations are shallow, and guarding of the area is often noted. Bruising may or may not be present.
Therefore, the remaining options are incorrect.
Question 5 of 5
One of the roles of the registered nurse in terms of informed consent is to:
Correct Answer: A
Rationale: The nurse's role in informed consent includes serving as a witness to the client's signature , confirming that the client signed voluntarily after being informed. The nurse does not obtain the consent or involve the durable power of attorney in signing .