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 nurse is teaching a client with a new diagnosis of asthma about self-management. Which of the following instructions should be included?
Correct Answer: A
Rationale: Daily peak flow meter use monitors lung function and guides asthma management.
Question 3 of 5
The A, B, C, and Ds of a complete and comprehensive nutritional assessment includes:
Correct Answer: D
Rationale: A comprehensive nutritional assessment includes Anthropometric data (e.g., height, weight), Biochemical data (e.g., lab values), Clinical data (e.g., physical signs), and Dietary data (e.g., intake history).
Question 4 of 5
Which adverse effect of heparin sodium therapy, delivered continuously by intravenous infusion, should the nurse monitor the client for?
Correct Answer: B
Rationale: Heparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The remaining options are not related side or adverse effects of this medication.
Question 5 of 5
The nurse is caring for a client with a history of venous thromboembolism who is prescribed rivaroxaban (Xarelto). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: Bleeding gums indicate a potential bleeding complication with rivaroxaban, requiring immediate reporting.