NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
The nurse holds the gauze pledget against an I.M. injection site while removing the needle from the muscle. This technique helps to:
Correct Answer: A
Rationale: Holding gauze against the injection site prevents medication leakage along the needle track, ensuring proper drug absorption.
Question 2 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 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 who is brought to the emergency department has experienced a burn covering greater than 25% of his total body surface area (TBSA). When reviewing the laboratory results drawn on the client, which value should the nurse most likely expect to note?
Correct Answer: A
Rationale: Extensive burns covering greater than 25% of the TBSA result in generalized body edema in both burned and nonburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels elevate in the first 24 hours after injury (the emergent phase) as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit is 42 to 52% (0.42-0.52) in the male and 37 to 47% (0.37-0.47) in the female. The normal albumin is 3.5-5 g/dL (35-50 g/L). The normal sodium level is 135 to 145 mEq/L (135-145 mmol/L). The normal WBC count is 5000 to 10,000 mm^3 (5-10 x 10^9/L).
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.