NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
A child is brought to the emergency department after being bitten on the arm by a neighborhood dog. Which is the priority question for the nurse to ask the parent of the child?
Correct Answer: C
Rationale: When a bite occurs, the injury site of the bite should be cleansed carefully and the child should be given tetanus prophylaxis if immunizations are not up-to-date. The remaining options identify information that may have to be obtained, but are not the priority questions. Additionally the mother may not have the answers to these questions.
Question 2 of 5
A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother?
Correct Answer: C
Rationale: Requesting the mother to leave ensures privacy for the teen, promoting honest responses during the sexual history.
Question 3 of 5
Which of the following patient care tasks is coupled with the appropriate member of the nursing care team in terms of their legal scope of practice?
Correct Answer: A
Rationale: Monitoring cardiac telemetry is within the scope of practice for unlicensed staff who are specifically trained and certified by the employing agency. Inserting a urinary catheter typically requires a higher level of licensure (e.g., LPN or RN), and LPNs are not typically authorized to serve as circulating nurses or first assistants in the perioperative area, as these roles require advanced training or RN licensure.
Question 4 of 5
A client is receiving a continuous infusion of heparin. The nurse notes a partial thromboplastin time (PTT) of 120 seconds. What should the nurse do first?
Correct Answer: A
Rationale: A PTT of 120 seconds is significantly above the therapeutic range (1.5 to 2 times normal), indicating a risk of bleeding. Stopping the infusion is the first action to prevent harm.
Question 5 of 5
You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client?
Correct Answer: C
Rationale: A multi-lumen tunneled and cuffed central venous catheter is ideal for long-term therapy due to its durability and lower infection risk.