NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 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 2 of 5
The nurse is administering a subcutaneous injection of heparin. Which technique ensures safe administration?
Correct Answer: D
Rationale: Pinching the skin creates a fold for subcutaneous injection, ensuring heparin is delivered into the correct tissue layer without damaging underlying structures.
Question 3 of 5
Intravenous 5% albumin is prescribed for a client with burns of the anterior chest and both legs. The nurse contacts the primary health care provider before administering the human albumin if which are noted in the client's record? Select all that apply.
Correct Answer: A,D
Rationale: Five percent albumin is classified as a blood derivative and is contraindicated in severe anemia, cardiac failure, history of allergic reaction, renal insufficiency, and when no albumin deficiency is present. It is used with caution in clients with low cardiac reserve, pulmonary disease, or hepatic or renal failure.
Question 4 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.
Question 5 of 5
The nurse is teaching a client with a new diagnosis of gout about dietary modifications. Which of the following foods should the client avoid?
Correct Answer: B
Rationale: Shellfish are high in purines, which can increase uric acid levels and trigger gout attacks.