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
The nurse is planning to initiate a blood transfusion. Which of the following solutions should the nurse select to prime the tubing when preparing to administer the blood?
Correct Answer: B
Rationale: Normal saline is compatible with blood and used to prime tubing to prevent hemolysis or clotting.
Question 3 of 5
A client with a history of bipolar disorder is prescribed valproic acid (Depakene). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: Yellowing of the skin indicates potential hepatotoxicity, a serious side effect of valproic acid, requiring immediate reporting.
Question 4 of 5
When assessing for signs of a blood transfusion reaction in a client with dark skin, the nurse should assess for which of the following?
Correct Answer: B
Rationale: Diaphoresis is a visible sign of a transfusion reaction, detectable regardless of skin tone, indicating an acute response.
Question 5 of 5
A nurse is administering I.V. fluids to a dehydrated client. When administering an I.V. solution of 3% sodium chloride, what should the nurse do? Select all that apply.
Correct Answer: A,B,C
Rationale: 3% sodium chloride is hypertonic and requires monitoring of intake/output, jugular veins for fluid overload, and neurologic status for hypernatremia effects. Forcing fluids or catheterization is not indicated.