NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 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.
Question 2 of 5
Which of the following measures should be implemented promptly after a client's nasogastric (NG) tube has been removed?
Correct Answer: A
Rationale: Oral hygiene removes residual tube-related irritation and promotes comfort after NG tube removal.
Question 3 of 5
A 10-year-old client with rheumatic fever is on bed rest. Which of the following would be an appropriate diversional activity for the nurse to encourage?
Correct Answer: B
Rationale: Coloring is a quiet, bed-appropriate activity that engages a 10-year-old without physical exertion, suitable for rheumatic fever recovery.
Question 4 of 5
While assessing the psychosocial aspects of a primigravid client at 30 weeks' gestation, which of the following feelings are expected?
Correct Answer: C
Rationale: Ambivalence is common in pregnancy, reflecting mixed emotions about impending motherhood and life changes.
Question 5 of 5
A client who has a history of chronic ulcerative colitis is diagnosed with anemia. The nurse interprets that which factor is most likely responsible for the anemia?
Correct Answer: A
Rationale: The client with chronic ulcerative colitis is most likely anemic as a result of chronic blood loss in small amounts that occurs with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. There is no information in the question to support options 2 or 4. In ulcerative colitis, the large intestine is involved, not the small intestine, where vitamin B12 and folic acid are absorbed.