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
The nurse is assessing a client with a suspected gastrointestinal bleed. Which of the following findings is most indicative of this condition?
Correct Answer: B
Rationale: Hypotension is a critical sign of a gastrointestinal bleed due to significant blood loss.
Question 3 of 5
A client with a history of chronic kidney disease is prescribed epoetin alfa (Epogen). The nurse should monitor the client for which of the following adverse effects? Select all that apply.
Correct Answer: A, B, E
Rationale: Epoetin alfa can cause hypertension, thrombosis, and headache due to increased red blood cell production.
Question 4 of 5
The mother of a child with newly diagnosed Duchenne's muscular dystrophy asks how her child developed the disease. The nurse formulates a response incorporating which of the following statements about its transmission?
Correct Answer: D
Rationale: Duchenne's muscular dystrophy is an X-linked recessive disorder, typically carried by females and transmitted to male children, who are more likely to express the disease.
Question 5 of 5
A client diagnosed with valvular heart disease is at risk for developing heart failure. What should the nurse assess as the priority when monitoring for heart failure?
Correct Answer: B
Rationale: Breath sounds are the best way to assess for the onset of heart failure. The presence of crackles or an increase in crackles is an indicator of fluid in the lungs caused by heart failure. The remaining options are components of the assessment but are less reliable indicators of heart failure.