NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
You are the Nurse Manager for the trauma unit. Which of these staff comments or statements indicate the need for you to provide an educational activity relating to confidentiality and information security?
Correct Answer: A,B,C
Rationale: Statements A, B, and C indicate breaches of confidentiality: an unattended computer with visible records , a student accessing unauthorized records , and a dietician accessing irrelevant notes . These require education on information security. Refusing to share a password is correct and does not indicate a need for education.
Question 2 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 3 of 5
To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which of the following positions in bed several times a day?
Correct Answer: A
Rationale: The prone position promotes hip extension, preventing flexion deformities common in rheumatoid arthritis.
Question 4 of 5
You are caring for a client who has been taking illicit amphetamines and states that they continue to use this illicit drug because they 'suffer and feel lousy' when they try to stop taking it. Which nursing diagnosis is the most appropriate for this client?
Correct Answer: D
Rationale: The client's symptoms of feeling 'lousy' when stopping the drug indicate physical dependence, as the body has adapted to the presence of amphetamines, leading to withdrawal symptoms upon cessation.
Question 5 of 5
The nurse is performing a physical assessment on a client with rheumatoid arthritis. The nurse assesses the client's hands and notes which characteristic deformities? Refer to the figure.
Correct Answer: A
Rationale: Ulnar drift occurs when synovitis stretches and damages the tendons, and eventually the tendons become shortened and fixed. This damage causes subluxation (drift) of the joints. All of the conditions that are identified in the options can occur in rheumatoid arthritis; however, the figure pictures ulnar drift.