NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse is teaching a client with hypertension about lifestyle modifications. Which of the following should the nurse include? Select all that apply.
Correct Answer: A, B, D, E
Rationale: Reducing sodium, regular aerobic exercise, maintaining healthy weight, and stress management help control hypertension. Moderate alcohol is acceptable, not total avoidance.
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 is making rounds and observes a client who is unconscious (see fi gure). The nursing assistant has just turned the client from lying on her back. Before raising the side rail, the nurse should:
Correct Answer: C
Rationale: The client is positioned correctly in the side-lying position. The pillows support the client’s joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client’s skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.
Question 4 of 5
You are the Nurse Manager for the trauma unit. Which of these staff comments or statements indicate the need for you to provide an educational activity relating to confidentiality and information security?
Correct Answer: A,B,C
Rationale: Statements A, B, and C indicate breaches of confidentiality: an unattended computer with visible records , a student accessing unauthorized records , and a dietician accessing irrelevant notes . These require education on information security. Refusing to share a password is correct and does not indicate a need for education.
Question 5 of 5
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
Correct Answer: B
Rationale: Jugular vein distension is a sign of tension pneumothorax due to increased intrathoracic pressure compressing the vena cava.