NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is teaching a client with a new diagnosis of type 1 diabetes about insulin administration. Which of the following instructions should be included?
Correct Answer: A, D
Rationale: Rotating injection sites prevents lipodystrophy, and room-temperature insulin reduces injection discomfort.
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
A client with a history of alcohol abuse is admitted with confusion and tremors. The nurse should prepare to administer which medication?
Correct Answer: A
Rationale: Thiamine is administered to prevent Wernicke's encephalopathy, a neurological complication of alcohol withdrawal associated with confusion and tremors.
Question 4 of 5
Your client had a ruptured appendix and peritonitis. What type of healing would be most likely for this client?
Correct Answer: A
Rationale: A ruptured appendix with peritonitis typically results in a wound that heals by secondary intention, where the wound is left open to heal from the base up due to infection.
Question 5 of 5
The nurse is monitoring a client diagnosed with hypercalcemia. Which assessment finding indicates a need for follow-up?
Correct Answer: B
Rationale: The client with hypercalcemia is at risk for formation of blood clots. Clotting is more likely to occur in the lower legs, pelvic region, and areas where blood flow is blocked (causing constriction). The nurse should assess for impaired blood flow by measuring calf circumference with a soft tape measure and assess temperature, color, and capillary refill. Decreased capillary refill may be indicative of a clot. The client with hypercalcemia may also exhibit decreased peristalsis, decreased deep tendon reflexes, altered level of consciousness, hypoactive or absent bowel sounds, or increased abdominal circumference as a result of decreased peristalsis.