NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next?
Correct Answer: C
Rationale: These symptoms are common side effects of lithium, especially early in treatment, and typically subside as the body adjusts. Continuing the medication and reassuring the client is appropriate unless symptoms worsen.
Question 2 of 5
A client who sustained a fractured leg has learned how to use crutches. The nurse should determine that the client has a need for further teaching if the client makes which statement about using crutches?
Correct Answer: D
Rationale: The client should use only crutches measured for the client. Crutches belonging to another person should not be used unless they have been adjusted to fit the client. Spare tips and crutches fitted to the client should be available if needed. Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The tips should be regularly inspected for wear.
Question 3 of 5
A tour bus has overturned on an exit ramp. Many passengers are injured, but there are no fatalities. While the emergency department nurse prepares for treating the injured, the nurse also calls the crisis nurse based on the understanding about which of the following?
Correct Answer: B
Rationale: A crisis nurse can address feelings of victimization, a common psychological response to traumatic accidents, providing emotional support.
Question 4 of 5
A client with a history of asthma is experiencing an acute exacerbation. Which medication should the nurse administer first?
Correct Answer: A
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma exacerbations to relieve bronchospasm and improve airflow.
Question 5 of 5
The nurse is assessing a client with a diagnosis of polycythemia vera. Which clinical manifestation should the nurse expect to note in this client?
Correct Answer: B
Rationale: Polycythemia vera is a myeloproliferative disease that causes increased blood viscosity and blood volume. Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness, headache, and a sense of fullness in the head. Signs of heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.