NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
A 30-year-old client is hospitalized with a fractured femur, which is being treated with skeletal traction. He states that he has not had a bowel movement for 2 days. Which of the following interventions is most appropriate at this time?
Correct Answer: C
Rationale: Increasing fluid intake promotes bowel motility, addressing constipation in a client immobilized by traction.
Question 2 of 5
Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify that the client: Select all that apply.
Correct Answer: C, D
Rationale: t-PA requires normal blood pressure and no active bleeding to minimize complications like hemorrhage.
Question 3 of 5
Which of the following is true with regard to delegation of client care responsibilities? Select all that apply.
Correct Answer: A, C, D, E
Rationale: Delegation involves understanding the care model, validating caregiver competency, determining tasks, and documenting delegation, but not delegating based solely on time demands.
Question 4 of 5
A 57-year-old Hispanic woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do?
Correct Answer: D
Rationale: A trained medical interpreter is required to ensure safety, accuracy of history data, and client confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture. Using the family member as interpreter violates the client's confidentiality. Using the nursing assistant or limited Spanish and nonverbal communication reduces the accuracy of interpretation and back-translation into English.
Question 5 of 5
Which of the following would be true regarding medication reconciliation? Select all that apply.
Correct Answer: A, B, D
Rationale: Medication reconciliation is a Joint Commission goal to ensure accurate medication lists across care transitions. Equivalent medications are reconciled, but not all staff are limited to nurses/providers, and not all medications are physician-ordered.