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 nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis?
Correct Answer: A
Rationale: A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle, which occurs in hydrocephalus. An elevated apical heart rate, proteinuria, and a drop in blood pressure are not specifically related to increasing cerebrospinal fluid in the brain tissue.
Question 3 of 5
After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next?
Correct Answer: C
Rationale: A negative contraction stress test indicates no fetal distress, so the nurse should next ensure contractions have ceased to prevent preterm labor. The other assessments are less immediate.
Question 4 of 5
A 14-month-old child has a severe diaper rash. Which of the following recommendations should the nurse provide to the parents?
Correct Answer: C
Rationale: Mild soap cleanses without irritating the rash, promoting healing, unlike wipes or powder, which may worsen it.
Question 5 of 5
A client with a history of depression is prescribed sertraline (Zoloft). The nurse should teach the client to report which side effect?
Correct Answer: C
Rationale: Suicidal thoughts are a serious side effect of SSRIs like sertraline, especially in the early weeks, requiring immediate reporting to ensure client safety.