NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 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 2 of 5
The physician has prescribed nitroglycerin to a client with angina. The client also has closed-angle glaucoma. The nurse contacts the physician to discuss the potential for:
Correct Answer: B
Rationale: Nitroglycerin can increase intraocular pressure, which is a concern in closed-angle glaucoma, potentially worsening the condition. Hypotension is a common side effect but not specific to glaucoma.
Question 3 of 5
The nurse is assessing a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What should the nurse determine is the possible cause of the bubbling?
Correct Answer: D
Rationale: Continuous bubbling in the water-seal chamber through both inspiration and expiration indicates that air is leaking into the system. A resolving pneumothorax would show intermittent bubbling in the water-seal chamber with respiration. Shutting the suction off to the system stops bubbling in the suction control chamber, but does not affect the water-seal chamber.
Question 4 of 5
For which of the following should the nurse be especially alert when caring for a term neonate, who weighed 10 lb at birth, 1 hour after a vaginal delivery?
Correct Answer: A
Rationale: The neonate would be considered large for gestational age (LG
A) because the neonate weighs more than 4,000 g (90th percentile). Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other complications like hyperbilirubinemia may occur, but hypoglycemia is the priority concern within the first hour.
Question 5 of 5
A client is prescribed risperidone. Which laboratory study should the nurse anticipate to be prescribed before the initiation of this medication therapy?
Correct Answer: C
Rationale: Risperidone is an atypical antipsychotic medication that suppresses behavioral response in psychosis. Baseline assessment includes renal and liver function tests, and these studies should be done before the initiation of treatment. This medication is used with caution in clients with renal or hepatic impairment, clients with underlying cardiovascular disorders, and in older or debilitated clients. None of the other options are related to the administration of this medication.