NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 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 2 of 5
The nurse is caring for a client post-total knee replacement. Which sign indicates a potential deep vein thrombosis?
Correct Answer: A
Rationale: Calf swelling and pain are classic signs of deep vein thrombosis, a common postoperative complication requiring immediate evaluation.
Question 3 of 5
A mother who is breast-feeding and has known food sensitivities is asking the nurse what foods she should avoid in her diet. The nurse should advise her to avoid which foods? Select all that apply.
Correct Answer: C
Rationale: Common food allergens like peanuts can pass through breast milk and cause reactions in sensitive infants. Fish, soy, beef, and lamb are less commonly associated with allergic reactions in breast-fed infants unless specific sensitivities are known.
Question 4 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 5 of 5
The nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis?
Correct Answer: A
Rationale: A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle, which occurs in hydrocephalus. An elevated apical heart rate, proteinuria, and a drop in blood pressure are not specifically related to increasing cerebrospinal fluid in the brain tissue.