NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next?
Correct Answer: C
Rationale: A negative contraction stress test indicates no fetal distress, so the nurse should next ensure contractions have ceased to prevent preterm labor. The other assessments are less immediate.
Question 2 of 5
The home care nurse visits a client who started wandering around at 10:00 pm each evening and got out of the house for the first time last night. The family asks for help. Which therapeutic response should the nurse make to the family?
Correct Answer: A
Rationale: The nurse responds to the family by assessing the situation and collecting additional data regarding the change in the client's behavior. The best response focuses on the family's problem so that the nurse can help develop potential strategies. Option 2 is giving advice. Option 3 is histrionic, invalidates the family's attempt to manage the client's care, and potentially causes resentment. Option 4 provides the nurse's conclusion based on an incomplete assessment; other factors may be causing confusion.
Question 3 of 5
A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal delivery. The physician has ordered I.M. prostagland in F₂a. After administration of the medication, the nurse should observe the client for which of the following?
Correct Answer: A
Rationale: Prostaglandin-F2α can cause tachycardia as a side effect due to its stimulatory effects on smooth muscle. Hypotension, constipation, and fever are less commonly associated.
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's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What should the nurse determine is the possible cause of the bubbling?
Correct Answer: D
Rationale: Continuous bubbling in the water-seal chamber through both inspiration and expiration indicates that air is leaking into the system. A resolving pneumothorax would show intermittent bubbling in the water-seal chamber with respiration. Shutting the suction off to the system stops bubbling in the suction control chamber, but does not affect the water-seal chamber.