NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
The nurse receives a specimen of clear, watery sputum from a client. Which of the following actions is most appropriate for the nurse to take?
Correct Answer: A
Rationale: Clear, watery sputum may indicate a condition like pulmonary edema, requiring prompt laboratory analysis for accurate diagnosis.
Question 2 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.
Question 3 of 5
A client is admitted to the hospital in myasthenic crisis. The nurse should ask the client about which precipitating factor for this event?
Correct Answer: B
Rationale: Myasthenic crisis is often caused by undermedication and responds to the administration of cholinergic medications such as neostigmine and pyridostigmine. Increased sleep and change in diet are not precipitating factors. However, overexertion and overeating could possibly trigger myasthenic crisis. Cholinergic crisis is caused by excess medication and responds to withholding of medications.
Question 4 of 5
The nurse is planning to initiate a blood transfusion. Which of the following solutions should the nurse select to prime the tubing when preparing to administer the blood?
Correct Answer: B
Rationale: Normal saline is compatible with blood and used to prime tubing to prevent hemolysis or clotting.
Question 5 of 5
A client has been given a prescription to begin using nitroglycerin transdermal medication patches. The nurse instructs the client about this medication administration system and provides which information? Select all that apply.
Correct Answer: B,C
Rationale: Nitroglycerin is a coronary vasodilator used in the management of coronary artery disease. The client is generally advised to apply a new medication patch each morning and leave it in place for 12 to 16 hours as the primary health care provider prescribes. The client needs the medication patch applied daily, not every 7 days, to ensure proper dosing is released as prescribed by the primary health care provider. The client can apply a new medication patch if it becomes dislodged because the dose is released continuously in small amounts through the skin. The client should avoid placing the medication patch in skinfolds or excoriated areas for appropriate absorption.