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
To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which of the following positions in bed several times a day?
Correct Answer: A
Rationale: The prone position promotes hip extension, preventing flexion deformities common in rheumatoid arthritis.
Question 3 of 5
A client has had a left mastectomy with axillary lymph node dissection. The nurse determines that the client understands postoperative restrictions and arm care when the client states the intention to engage in which activity?
Correct Answer: A
Rationale: The client is at risk for edema and infection as a result of lymph node dissection. The client should use a variety of techniques to avoid trauma to the affected arm. Examples include using gloves when working in the garden, an electric razor to shave under the arm, and pot holders when cooking to prevent burns. The client should also avoid activities that increase edema, such as carrying heavy objects or having blood pressures taken on the affected arm.
Question 4 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 5 of 5
The nurse is caring for a client with a history of burns. Which of the following interventions should be included in the plan of care?
Correct Answer: A
Rationale: Monitoring for infection is critical in burns due to high risk of sepsis.