NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 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 2 of 5
Which site or technique would you expect to use to administer ferrous sulfate?
Correct Answer: C
Rationale: The Z-track technique is used for ferrous sulfate IM injections to prevent leakage and skin staining.
Question 3 of 5
A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.
Question 4 of 5
A 57-year-old Hispanic woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do?
Correct Answer: D
Rationale: A trained medical interpreter is required to ensure safety, accuracy of history data, and client confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture. Using the family member as interpreter violates the client's confidentiality. Using the nursing assistant or limited Spanish and nonverbal communication reduces the accuracy of interpretation and back-translation into English.
Question 5 of 5
The nurse is teaching a client with a new diagnosis of asthma about self-management. Which of the following instructions should be included?
Correct Answer: A
Rationale: Daily peak flow meter use monitors lung function and guides asthma management.