NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
A client with a history of liver failure is admitted with hepatic encephalopathy. The nurse should monitor the client for which of the following?
Correct Answer: A
Rationale: Asterixis (flapping tremor) is a hallmark sign of hepatic encephalopathy due to ammonia buildup.
Question 2 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 3 of 5
After abdominal surgery, a client has an order for meperidine (Demerol) I.M. 100 mg every 3 to 4 hours and acetaminophen (Tylenol) with codeine 30 mg. The client has been taking meperidine every 4 hours for the past 48 hours, but she tells the nurse that the meperidine is no longer lasting 4 hours and she needs to have it every 3 hours. Which of the following nursing actions is most appropriate?
Correct Answer: C
Rationale: Increasing frequency suggests tolerance; switching to an equianalgesic dose of morphine may provide better pain control without escalating doses.
Question 4 of 5
Which of these statements related to information technology is accurate?
Correct Answer: B
Rationale: The most common breaches of healthcare data security occur internally by staff , through actions like unauthorized access or improper handling of information, rather than external hackers or low-risk social media . Data deletion does not always destroy all evidence.
Question 5 of 5
The nurse is assessing a client with a suspected gastrointestinal bleed. Which of the following findings is most indicative of this condition?
Correct Answer: B
Rationale: Hypotension is a critical sign of a gastrointestinal bleed due to significant blood loss.