NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
The nurse is assessing the perineal changes of a woman in the second stage of labor. The nurse expects to see which of the following changes?
Correct Answer: D
Rationale: Crowning, when the fetal head is visible at the vaginal opening, is the expected perineal change in the second stage of labor, indicating imminent delivery.
Question 2 of 5
A client is scheduled for a colonoscopy. Which of the following instructions should the nurse include in the pre-procedure teaching?
Correct Answer: A, C
Rationale: Clear liquid diet for 24 hours prevents residue, and sedation is common during colonoscopy. Regular medications may need adjustment, and overnight stays are not typical.
Question 3 of 5
Which of the following patient care tasks is coupled with the appropriate member of the nursing care team in terms of their legal scope of practice?
Correct Answer: A
Rationale: Monitoring cardiac telemetry is within the scope of practice for unlicensed staff who are specifically trained and certified by the employing agency. Inserting a urinary catheter typically requires a higher level of licensure (e.g., LPN or RN), and LPNs are not typically authorized to serve as circulating nurses or first assistants in the perioperative area, as these roles require advanced training or RN licensure.
Question 4 of 5
The nurse is caring for a postoperative client who reports a pain level of 8 out of 10. The client has an order for morphine 4 mg IV every 4 hours as needed. What is the nurse's priority action?
Correct Answer: B
Rationale: Assessing vital signs and pain characteristics ensures the pain is accurately evaluated and the morphine is safe to administer, considering potential side effects like respiratory depression.
Question 5 of 5
A client with a history of gout is prescribed febuxostat (Uloric). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Febuxostat can cause hepatotoxicity, requiring liver function monitoring.