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
The nurse is assessing a client with a suspected gastrointestinal bleed. Which of the following findings is most indicative of this condition?
Correct Answer: B
Rationale: Hypotension is a critical sign of a gastrointestinal bleed due to significant blood loss.
Question 3 of 5
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse should expect to observe which of the following symptoms?
Correct Answer: B
Rationale: A high-pitched cry is a common symptom of bacterial meningitis in infants, indicating neurological irritation.
Question 4 of 5
The nursing assessment of a client with osteomyelitis of the left great toe reveals pain with partial weight-bearing, unsteady gait, and fever. The priority nursing diagnosis for the client is:
Correct Answer: D
Rationale: Risk for injury is the priority due to unsteady gait and pain, which increase the likelihood of falls in a client with osteomyelitis.
Question 5 of 5
Which of the following is true with regard to delegation of client care responsibilities? Select all that apply.
Correct Answer: A, C, D, E
Rationale: Delegation involves understanding the care model, validating caregiver competency, determining tasks, and documenting delegation, but not delegating based solely on time demands.