NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
A client who has a history of chronic ulcerative colitis is diagnosed with anemia. The nurse interprets that which factor is most likely responsible for the anemia?
Correct Answer: A
Rationale: The client with chronic ulcerative colitis is most likely anemic as a result of chronic blood loss in small amounts that occurs with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. There is no information in the question to support options 2 or 4. In ulcerative colitis, the large intestine is involved, not the small intestine, where vitamin B12 and folic acid are absorbed.
Question 2 of 5
The sense of hearing is assessed using which standardized test?
Correct Answer: B
Rationale: The Rinne test is a standardized test used to assess hearing by comparing air and bone conduction using a tuning fork.
Question 3 of 5
The nurse is preparing to care for a client who has undergone esophagogastroduodenoscopy (EGD). After checking the vital signs, what should be the nurse's next priority?
Correct Answer: C
Rationale: The nurse places highest priority on assessing for the return of the gag reflex, which is part of maintaining the client's airway. The nurse should also monitor the client for sharp pain (may indicate a potential complication) and heartburn. The client would receive warm gargles, but this cannot be done until the gag reflex has returned.
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
The nurse is teaching a client with asthma about the use of a peak flow meter. Which of the following instructions should be included?
Correct Answer: B, C
Rationale: Recording the highest of three readings ensures accuracy, and cleaning the meter weekly prevents contamination.