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
The nurse is beginning the shift and is now responsible for the following clients on the postpartum unit and has not yet made rounds on the clients. Additionally, the nurse is responsible for three other clients who are currently listed as stable. The nurse will also be getting a new admission in 15 minutes. For the best utilization of time and client safety, the nurse should make rounds on which of the following clients first?
Correct Answer: B
Rationale: The infant with a blood glucose of $15 \mathrm{mg} / \mathrm{dL}$ is critically low, indicating severe hypoglycemia, which requires immediate intervention to prevent neurological damage.
Question 3 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 4 of 5
A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When asking this client to complete a task, what techniques should the nurse use to communicate most effectively with him?
Correct Answer: A
Rationale: Clear, simple instructions with eye contact and repetition enhance communication for a child with ADHD, and praise reinforces positive behavior.
Question 5 of 5
The mother of a newborn is voicing concerns about her baby's ability to hear. The nurse should tell the mother:
Correct Answer: C
Rationale: Most states mandate newborn hearing screening to detect issues early, addressing the mother's concern appropriately without dismissing it or suggesting unreliable home testing.