NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
While assessing a neonate at age 24 hours, the nurse observes several irregularly shaped, red, flat patches on the back of the neonate's neck. The nurse interprets this finding as which of the following?
Correct Answer: A
Rationale: Stork bites are common, benign, red, flat patches on a neonate's neck or face that typically fade over time. Port wine stains are darker and persistent, newborn rash is more generalized, and café au lait spots are pigmented and light brown.
Question 2 of 5
A client is being discharged from the hospital after removal of chest tubes that were inserted following thoracic surgery. When providing home care instructions to the client, which client statement indicates a need for further teaching?
Correct Answer: C
Rationale: Upon removal of a chest tube, a dressing is usually placed over the chest tube site. This is maintained in place until the primary health care provider says it may be removed. The client should avoid heavy lifting for the first 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any respiratory difficulty or increased temperature.
Question 3 of 5
A client was admitted to the hospital with a diagnosis of frequent symptomatic premature ventricular contractions (PVCs). After sitting up in a chair for a few minutes, the client reports feeling lightheaded. Which finding should the nurse anticipate on auscultation of the heartbeat?
Correct Answer: B
Rationale: The most accurate means of assessing pulse rhythm is by auscultation of the apical pulse. When a client has PVCs, the rate is irregular and if the radial pulse is taken, a true picture of what is occurring is not obtained. A very slow regular apical pulse indicates bradycardia. A very rapid regular apical pulse indicates tachycardia.
Question 4 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.
Question 5 of 5
The nurse is teaching a client about the use of a metered-dose inhaler with a spacer. Which step should the client perform first?
Correct Answer: A
Rationale: Shaking the inhaler first ensures the medication is properly mixed for effective delivery through the spacer.