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 with an injury to the thalamus. The nurse should plan to:
Correct Answer: C
Rationale: The thalamus regulates body temperature, so an injury may impair thermoregulation. Monitoring bathwater temperature prevents burns or discomfort. Pain medication, eye patches, or avoiding movement are not directly related to thalamic injury.
Question 3 of 5
Select the step of blood glucose level monitoring that is NOT accurate.
Correct Answer: D
Rationale: Pricking the pad of the finger is less accurate and more painful; the side of the finger is the preferred site for blood glucose monitoring.
Question 4 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 5 of 5
A client diagnosed with valvular heart disease is at risk for developing heart failure. What should the nurse assess as the priority when monitoring for heart failure?
Correct Answer: B
Rationale: Breath sounds are the best way to assess for the onset of heart failure. The presence of crackles or an increase in crackles is an indicator of fluid in the lungs caused by heart failure. The remaining options are components of the assessment but are less reliable indicators of heart failure.