NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse is caring for a client who has just undergone a total knee replacement. Which of the following interventions is most important in the immediate postoperative period?
Correct Answer: B
Rationale: Applying ice packs reduces swelling and pain post-knee replacement, promoting recovery.
Question 3 of 5
A 10-year-old client with rheumatic fever is on bed rest. Which of the following would be an appropriate diversional activity for the nurse to encourage?
Correct Answer: B
Rationale: Coloring is a quiet, bed-appropriate activity that engages a 10-year-old without physical exertion, suitable for rheumatic fever recovery.
Question 4 of 5
Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next?
Correct Answer: C
Rationale: These symptoms are common side effects of lithium, especially early in treatment, and typically subside as the body adjusts. Continuing the medication and reassuring the client is appropriate unless symptoms worsen.
Question 5 of 5
A client with a history of Addison's disease is prescribed hydrocortisone. The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: C
Rationale: Mood changes may indicate corticosteroid excess, requiring immediate reporting to adjust the hydrocortisone dose.