NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is preparing to give an I.M. injection. Which of the following sites has the least amount of blood vessels and major nerves located in the area?
Correct Answer: C
Rationale: The vastus lateralis has fewer blood vessels and nerves compared to the deltoid, dorsogluteal, or triceps, making it a safer site for I.M. injections.
Question 2 of 5
A client is being discharged after undergoing a transurethral resection of the prostate (TURP). The nurse teaches the client to expect which variation in normal urine color for several days after the procedure?
Correct Answer: B
Rationale: The client should expect that the urine will be pink-tinged for several days after this procedure. Dark red urine may be present initially, especially with inadequate bladder irrigation, and if it occurs, it must be corrected. Clear urine is not expected after surgery; cloudy urine could indicate an infection.
Question 3 of 5
A client is being discharged from the hospital after removal of chest tubes that were inserted following thoracic surgery. When providing home care instructions to the client, which client statement indicates a need for further teaching?
Correct Answer: C
Rationale: Upon removal of a chest tube, a dressing is usually placed over the chest tube site. This is maintained in place until the primary health care provider says it may be removed. The client should avoid heavy lifting for the first 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any respiratory difficulty or increased temperature.
Question 4 of 5
Which of the following responses is most helpful for a client who is euphoric, intrusive, and interrupts other clients engaged in conversations to the point where they get up and leave or walk away?
Correct Answer: A
Rationale: This response provides objective feedback about the behavior's impact, encouraging self-awareness without being judgmental, which is therapeutic for a client with euphoria, likely in a manic state.
Question 5 of 5
A 2-month-old infant is brought to the clinic with a fever of 101°F (38.3°C). What should the nurse instruct the parents to do first?
Correct Answer: C
Rationale: A fever in a 2-month-old is a medical emergency due to the risk of serious bacterial infection. Immediate medical attention is required.