NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
A client who is brought to the emergency department has experienced a burn covering greater than 25% of his total body surface area (TBSA). When reviewing the laboratory results drawn on the client, which value should the nurse most likely expect to note?
Correct Answer: A
Rationale: Extensive burns covering greater than 25% of the TBSA result in generalized body edema in both burned and nonburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels elevate in the first 24 hours after injury (the emergent phase) as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit is 42 to 52% (0.42-0.52) in the male and 37 to 47% (0.37-0.47) in the female. The normal albumin is 3.5-5 g/dL (35-50 g/L). The normal sodium level is 135 to 145 mEq/L (135-145 mmol/L). The normal WBC count is 5000 to 10,000 mm^3 (5-10 x 10^9/L).
Question 2 of 5
The nurse should instruct the parent of a child who is taking valproic acid (Depakene) that the child will need to have routine blood analyses consisting of which of the following?
Correct Answer: B
Rationale: Valproic acid requires monitoring of amylase (for pancreatitis) and platelet levels (for thrombocytopenia).
Question 3 of 5
A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is prescribed ipratropium (Atrovent). The nurse should teach the client that this medication works by:
Correct Answer: B
Rationale: Ipratropium, an anticholinergic, dilates bronchioles, improving airflow in COPD.
Question 4 of 5
Which of the following would be true regarding medication reconciliation? Select all that apply.
Correct Answer: A, B, D
Rationale: Medication reconciliation is a Joint Commission goal to ensure accurate medication lists across care transitions. Equivalent medications are reconciled, but not all staff are limited to nurses/providers, and not all medications are physician-ordered.
Question 5 of 5
A client with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome confides that he is homosexual and his employer does not know his HIV status. Which response by the nurse is best?
Correct Answer: B
Rationale: The nurse is responsible for maintaining confidentiality of this disclosure by the client. Sharing personal health information without consent violates patient privacy laws, such as HIPAA, except in specific circumstances like public health reporting. Offering to help disclose or sharing with family or employer without consent is inappropriate.