NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
Number the priority of the following conditions using the numbers # 1 through # 6 with # 1 as the greatest priority and # 6 as the least priority. 1. Atrial fibrillation 2. First degree heart block 3. Shortness of breath upon exertion 4. An obstructed airway 5. Fluid needs 6. Respect and esteem by others
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework and Maslow's hierarchy, the correct order is: An obstructed airway (4, #1, life-threatening), Shortness of breath upon exertion (3, #2, breathing issue), Fluid needs (5, #3, physiological need), Atrial fibrillation (1, #4, potential circulatory issue), First degree heart block (2, #5, often asymptomatic), Respect and esteem by others (6, #6, psychological need). Thus, B (3,4,5,1,2,6) is correct.
Question 2 of 5
A primigravid client at 10 weeks' gestation tells the nurse that she eats fruits and vegetables but isn't fond of them. After teaching the client about possible serving sizes, the nurse determines that the teaching has been successful when the client states that one serving of fruit is equivalent to which of the following?
Correct Answer: A
Rationale: One serving of fruit is equivalent to one-fourth of a cantaloupe. The client needs $6 \mathrm{oz}$ of a vegetable juice cocktail, two tomatoes, or two raw apricots to meet one fruit serving.
Question 3 of 5
A client with a history of gastroesophageal reflux disease (GERD) is admitted with chest pain. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: Chest pain in GERD may mimic cardiac pain, so obtaining a 12-lead ECG rules out myocardial infarction.
Question 4 of 5
A child with a diagnosis of sickle cell disease is admitted to the hospital for treatment of vaso-occlusive pain crisis. The nurse should plan for which interventions in the care of the client? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Management of the severe pain that occurs with vaso-occlusive crisis includes frequent pain assessment and the use of strong opioid analgesics, such as morphine sulfate and hydromorphone. Fluids are necessary to promote hydration, so options related to the delivery of fluids are appropriate. Oxygen is administered to increase tissue perfusion. Meperidine is contraindicated because of its side effects and increased risk of seizures after as few as 2 doses.
Question 5 of 5
The nurse is caring for a client with a history of multiple sclerosis. Which of the following interventions should be included in the plan of care?
Correct Answer: A
Rationale: Daily exercise helps maintain mobility and strength in multiple sclerosis.