NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 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 2 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 3 of 5
A client has cystitis. The nurse should further assess the client for:
Correct Answer: D
Rationale: Foul-smelling urine is a common symptom of cystitis due to bacterial infection. Flank pain and oliguria are more indicative of pyelonephritis.
Question 4 of 5
A client with alcohol dependence states, 'I feel so bad because of what I've done to my wife and kids. I'm just no good.' Which of the following responses by the nurse is most appropriate?
Correct Answer: C
Rationale: Framing alcohol dependence as a treatable disease offers hope and reduces self-blame, supporting recovery. Other responses may reinforce guilt or are less therapeutic.
Question 5 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.