NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
When assessing a dark-skinned client for cyanosis, the nurse should examine which of the following?
Correct Answer: C
Rationale: The oral mucous membranes are the most reliable site for assessing cyanosis in dark-skinned clients, as they show color changes more clearly.
Question 2 of 5
The nurse is caring for a client with a history of hyperlipidemia who is prescribed atorvastatin (Lipitor). Which of the following laboratory tests should the nurse monitor?
Correct Answer: B
Rationale: Atorvastatin can cause hepatotoxicity, requiring regular monitoring of liver function tests.
Question 3 of 5
A client with a head injury and a feeding tube continuously tries to remove the tube. The nurse contacts the primary health care provider who prescribes the use of restraints. After checking the agency's policy and procedure regarding the use of restraints, the nurse uses which method in restraining the client?
Correct Answer: D
Rationale: Mitten restraints are useful for this client because the client cannot pull against them, creating resistance that could lead to increased intracranial pressure (ICP). Belt and waist restraints prevent the client from getting up or falling out of bed or off a stretcher but do nothing to limit hand movement. Wrist restraints cause resistance.
Question 4 of 5
The nurse caring for a client with diabetes realizes that the client has a higher risk of developing cataracts and:
Correct Answer: D
Rationale: Diabetic retinopathy, encompassing both background and proliferative types, is a common complication of diabetes due to chronic hyperglycemia affecting retinal blood vessels.
Question 5 of 5
Which is a sign of thrombocytopenia?
Correct Answer: A
Rationale: Petechiae, small red or purple spots on the skin, are a hallmark sign of thrombocytopenia due to low platelet counts.