NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
A client has cystitis. The nurse should further assess the client for:
Correct Answer: D
Rationale: Foul-smelling urine is a common symptom of cystitis due to bacterial infection. Flank pain and oliguria are more indicative of pyelonephritis.
Question 2 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 3 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 4 of 5
The nurse is assessing a client with a diagnosis of polycythemia vera. Which clinical manifestation should the nurse expect to note in this client?
Correct Answer: B
Rationale: Polycythemia vera is a myeloproliferative disease that causes increased blood viscosity and blood volume. Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness, headache, and a sense of fullness in the head. Signs of heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.
Question 5 of 5
Which member of the multidisciplinary team would you most likely collaborate with when your pediatric client has had a traumatic amputation one or more months ago?
Correct Answer: D
Rationale: A prosthetist specializes in designing and fitting prosthetic limbs, making them the most appropriate team member to collaborate with for a pediatric client with a traumatic amputation.