NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
Which of the following nursing diagnoses is a priority for the family whose child is dying of leukemia?
Correct Answer: D
Rationale: Grieving is the priority nursing diagnosis for a family with a child dying of leukemia, as it addresses their emotional response to impending loss. Other diagnoses may apply but are less immediate.
Question 2 of 5
The nurse is assessing fetal position in a 32-year-old woman in her eighth month of pregnancy. From the fi gure below, the fetal position can be described as:
Correct Answer: D
Rationale: In right occipital anterior lie, the occiput faces the right anterior segment of the woman’s pelvis. In left occipital transverse lie, the occiput faces the woman’s left hip. In left occipital anterior lie, the occiput faces the left anterior segment of the woman’s pelvis. In right occipital transverse lie, the occiput faces the woman’s right hip.
Question 3 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 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 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.