NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the chart for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 3:30 p.m. is 75%. What should the nurse do first?
Correct Answer: C
Rationale: A pulse oximetry reading of 75% is concerning but may be due to probe misplacement. Reassessing the reading first confirms accuracy before escalating to invasive measures like blood gases.
Question 2 of 5
The nurse is caring for a client who has just returned to the nursing unit after an intravenous pyelogram (IVP). Which of the following nursing interventions is most appropriate at this time?
Correct Answer: A
Rationale: Encouraging a large fluid intake post-IVP helps flush the contrast dye from the kidneys, reducing the risk of nephrotoxicity.
Question 3 of 5
A 14-month-old child has a severe diaper rash. Which of the following recommendations should the nurse provide to the parents?
Correct Answer: C
Rationale: Mild soap cleanses without irritating the rash, promoting healing, unlike wipes or powder, which may worsen it.
Question 4 of 5
The client has been prescribed lisinopril (Prinivil) to treat hypertension. The nurse should assess the client for which of the following electrolyte imbalances?
Correct Answer: A
Rationale: Lisinopril, an ACE inhibitor, can cause hyponatremia due to its effects on sodium excretion. Hypocalcemia and hypermagnesemia are not commonly associated with this medication.
Question 5 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.