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 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
The nurse is caring for a client with a history of breast cancer who is receiving radiation therapy. Which of the following instructions should the nurse include in the client's teaching?
Correct Answer: B
Rationale: Avoiding sunlight exposure protects the radiated skin from further damage and reduces irritation.
Question 4 of 5
Identify this cardiac rhythm strip. Fill in the blank. A. Third Degree Heart Block B. Second-Degree Atrioventricular Block, Type II C. Ventricular fibrillation D. Premature Atrial Contractions
Correct Answer: A
Rationale: Third Degree Heart Block shows complete dissociation between P waves and QRS complexes, assuming the strip matches this description.
Question 5 of 5
Which of the following is true with regard to delegation of client care responsibilities? Select all that apply.
Correct Answer: A, C, D, E
Rationale: Delegation involves understanding the care model, validating caregiver competency, determining tasks, and documenting delegation, but not delegating based solely on time demands.