NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
A client with a history of depression is prescribed sertraline (Zoloft). The nurse should teach the client to report which side effect?
Correct Answer: C
Rationale: Suicidal thoughts are a serious side effect of SSRIs like sertraline, especially in the early weeks, requiring immediate reporting to ensure client safety.
Question 2 of 5
The nursing assessment of a client with osteomyelitis of the left great toe reveals pain with partial weight-bearing, unsteady gait, and fever. The priority nursing diagnosis for the client is:
Correct Answer: D
Rationale: Risk for injury is the priority due to unsteady gait and pain, which increase the likelihood of falls in a client with osteomyelitis.
Question 3 of 5
The nurse should instruct a client who is taking dexamethasone (Decadron) and furosemide (Lasix) to report:
Correct Answer: B
Rationale: Muscle weakness is a serious side effect of dexamethasone (steroid-induced myopathy) and furosemide (potassium loss), requiring prompt reporting.
Question 4 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.
Question 5 of 5
A 10-year-old client with rheumatic fever is on bed rest. Which of the following would be an appropriate diversional activity for the nurse to encourage?
Correct Answer: B
Rationale: Coloring is a quiet, bed-appropriate activity that engages a 10-year-old without physical exertion, suitable for rheumatic fever recovery.