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NCLEX RN· Reduction of Risk Potential · NCLEX RN Reduction of Risk Potential

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

A student nurse is discussing fluid overload with the staff nurse. Which statement by the student nurse indicates a need for further explanation by the staff nurse?

A. Pitting edema is the best indicator of fluid overload.

B. The client may have distended veins in the hands and neck.

C. I may hear moist crackles in the lungs during my respiratory assessment.

D. The client may need drug therapy and sodium restriction to treat the overload.

Expert Explanatory Rationale

Correct Answer: Pitting edema is the best indicator of fluid overload.

Question 2 of 5

The nurse is preparing the client for a liver biopsy. Which statement by the client indicates a need for further instruction regarding the procedure?

A. I can resume strenuous activity in 2 to 3 days.

B. I will have to lay on my right side after the procedure.

C. I will have a small bandage instead of stitches afterward.

D. My right shoulder may begin to hurt as the anesthesia wears off.

E. I may have a small amount of pain or discomfort during the procedure.

Expert Explanatory Rationale

Correct Answer: I can resume strenuous activity in 2 to 3 days.

Question 3 of 5

A 10-year-old is sent home from school with a report of having lice. The nurse should instruct the parent on which intervention?

A. wash the hair for three continuous days with dandruff shampoo

B. isolate all clothing of the child for one week

C. treat with an approved pediculicide agent according to directions

D. shave the child's head, then cleanse with herbal shampoo

Expert Explanatory Rationale

Correct Answer: treat with an approved pediculicide agent according to directions

Question 4 of 5

A nurse is preparing discharge instructions for a client with a below-the-knee amputation. Which instruction would be a priority?

A. sterile wound management

B. elevation of residual limb

C. performing prescribed exercises

D. reporting occurrence of phantom limb pain immediately

Expert Explanatory Rationale

Correct Answer: elevation of residual limb

Question 5 of 5

The nurse is assisting the health care provider to perform a renal biopsy. Which position should the nurse place the client in?

A. in the semi-Fowler's position

B. on the same side of the kidney to be biopsied

C. on the side opposite of the kidney to be biopsied

D. prone with a pillow under the shoulders and abdomen

Expert Explanatory Rationale

Correct Answer: prone with a pillow under the shoulders and abdomen

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