NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse observes that a client who has received midazolam (Versed) for local anesthesia is having shallow respirations. The nurse should:
Correct Answer: C
Rationale: Midazolam can cause respiratory depression, so administering oxygen as ordered is the most appropriate initial response.
Question 2 of 5
The nurse in a rehabilitation center is planning the client assignments for the day. Which client has needs that can be most safely met by the unlicensed assistive personnel (UAP)?
Correct Answer: A
Rationale: The nurse must assign tasks based on the guidelines of nursing practice acts and the job description of the employing agency. Unlicensed assistive personnel are trained to care for the client on bed rest and to maintain 24-hour urine collections. The nurse should provide instructions to unlicensed assistive personnel regarding the tasks, but the tasks required for this client are within the role description of unlicensed assistive personnel. A client scheduled to be transferred to the hospital for coronary artery bypass surgery, a client scheduled for an invasive diagnostic procedure, and a client who had a BKA have both physiological and psychosocial needs.
Question 3 of 5
A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, 'I want to see the baby one last time.' Which of the following should the nurse do?
Correct Answer: D
Rationale: Allowing the client to see and hold the baby supports emotional closure and respects her autonomy in this significant decision.
Question 4 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.
Question 5 of 5
A client with a history of schizophrenia is prescribed risperidone (Risperdal). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Risperidone can cause extrapyramidal symptoms, such as tremors and rigidity, requiring monitoring.