NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is teaching a client about warfarin (Coumadin) therapy. Which statement indicates the client understands the teaching?
Correct Answer: B
Rationale: Warfarin increases bleeding risk, so reporting bruising or bleeding is critical to monitor for complications like hemorrhage.
Question 2 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 3 of 5
A client with a history of type 1 diabetes mellitus is prescribed insulin glargine (Lantus). The nurse should explain that this insulin:
Correct Answer: B
Rationale: Insulin glargine provides a steady basal insulin level over 24 hours, used for long-term glucose control.
Question 4 of 5
A client was admitted to the hospital with a diagnosis of frequent symptomatic premature ventricular contractions (PVCs). After sitting up in a chair for a few minutes, the client reports feeling lightheaded. Which finding should the nurse anticipate on auscultation of the heartbeat?
Correct Answer: B
Rationale: The most accurate means of assessing pulse rhythm is by auscultation of the apical pulse. When a client has PVCs, the rate is irregular and if the radial pulse is taken, a true picture of what is occurring is not obtained. A very slow regular apical pulse indicates bradycardia. A very rapid regular apical pulse indicates tachycardia.
Question 5 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.