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
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 3 of 5
The nurse delegates the care of a multiparous client who delivered a viable term neonate vaginally 30 hours ago and is preparing to be discharged to a licensed practical nurse (LPN). The nurse should instruct the LPN to notify the nurse if the client exhibits which of the following?
Correct Answer: A
Rationale: A pulse rate of 100 bpm may indicate postpartum complications like hemorrhage or infection, requiring nurse notification.
Question 4 of 5
Your client has a doctor's order for 1200 mLs of intravenous fluid every 8 hours. Your shift began at 8 am and there were 600 mLs remaining in the intravenous fluid bag. How many mLs would you expect to see at 12 noon?
Correct Answer: A
Rationale:
To calculate: 1,200 mL ÷ 8 hours = 150 mL/hr. From 8 AM to 12 noon (4 hours), 4 × 150 = 600 mL infused. Starting with 600 mL, 600 - 600 = 0 mL remaining.
Question 5 of 5
The nurse teaches the client with cirrhosis that he is achieving the expected effect of lactulose (Cephulac) when he has:
Correct Answer: B
Rationale: Lactulose is used in cirrhosis to reduce ammonia levels by promoting 2–3 soft stools per day. Fewer or more frequent stools may indicate under- or overdosing.