NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
Your client had a ruptured appendix and peritonitis. What type of healing would be most likely for this client?
Correct Answer: A
Rationale: A ruptured appendix with peritonitis heals by secondary intention, as the wound is left open to heal from the base up due to infection.
Question 2 of 5
The nurse is preparing to give an I.M. injection. Which of the following sites has the least amount of blood vessels and major nerves located in the area?
Correct Answer: C
Rationale: The vastus lateralis has fewer blood vessels and nerves compared to the deltoid, dorsogluteal, or triceps, making it a safer site for I.M. injections.
Question 3 of 5
Select the client who is at greatest risk for impaired vascular perfusion.
Correct Answer: C
Rationale: Cigarette smoking is a major risk factor for impaired vascular perfusion due to its effects on endothelial damage and atherosclerosis, significantly increasing the risk of peripheral vascular disease.
Question 4 of 5
A client has had a left mastectomy with axillary lymph node dissection. The nurse determines that the client understands postoperative restrictions and arm care when the client states the intention to engage in which activity?
Correct Answer: A
Rationale: The client is at risk for edema and infection as a result of lymph node dissection. The client should use a variety of techniques to avoid trauma to the affected arm. Examples include using gloves when working in the garden, an electric razor to shave under the arm, and pot holders when cooking to prevent burns. The client should also avoid activities that increase edema, such as carrying heavy objects or having blood pressures taken on the affected arm.
Question 5 of 5
A client with heart failure is prescribed spironolactone (Aldactone). The nurse should monitor for which of the following electrolyte imbalances?
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, increasing the risk of hyperkalemia. Hypokalemia is associated with loop diuretics, and hyponatremia or hypercalcemia are less likely.