NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
A 10-year-old client with rheumatic fever is on bed rest. Which of the following would be an appropriate diversional activity for the nurse to encourage?
Correct Answer: B
Rationale: Coloring is a quiet, bed-appropriate activity that engages a 10-year-old without physical exertion, suitable for rheumatic fever recovery.
Question 2 of 5
A client with a history of gastroesophageal reflux disease (GERD) is admitted with chest pain. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: Chest pain in GERD may mimic cardiac pain, so obtaining a 12-lead ECG rules out myocardial infarction.
Question 3 of 5
Your client has an allergy to both penicillin and latex. Which of these pathophysiological facts should you apply when you are providing to this client?
Correct Answer: A
Rationale: A sensitizing dose of penicillin can lead to anaphylaxis , a life-threatening allergic reaction, which is critical to consider when caring for a client with a penicillin allergy. The prevalence of dual allergies (C,
D) is not accurate, and distributive shock is not specific to a second dose.
Question 4 of 5
The nurse on the antenatal unit is planning care for four clients. The nurse should assess which of the following clients first?
Correct Answer: B
Rationale: The 19-year-old with bright red vaginal bleeding post-accident at 18 weeks is at high risk for miscarriage or placental abruption, requiring immediate assessment. The other clients are stable or less acute.
Question 5 of 5
A client who is brought to the emergency department has experienced a burn covering greater than 25% of his total body surface area (TBSA). When reviewing the laboratory results drawn on the client, which value should the nurse most likely expect to note?
Correct Answer: A
Rationale: Extensive burns covering greater than 25% of the TBSA result in generalized body edema in both burned and nonburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels elevate in the first 24 hours after injury (the emergent phase) as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit is 42 to 52% (0.42-0.52) in the male and 37 to 47% (0.37-0.47) in the female. The normal albumin is 3.5-5 g/dL (35-50 g/L). The normal sodium level is 135 to 145 mEq/L (135-145 mmol/L). The normal WBC count is 5000 to 10,000 mm^3 (5-10 x 10^9/L).