NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a chest tube. Which observation indicates a potential complication?
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate investigation.
Question 2 of 5
The sense of hearing is assessed using which standardized test?
Correct Answer: B
Rationale: The Rinne test is a standardized test used to assess hearing by comparing air and bone conduction using a tuning fork.
Question 3 of 5
The nurse is caring for a client with a history of venous thromboembolism who is prescribed rivaroxaban (Xarelto). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: Bleeding gums indicate a potential bleeding complication with rivaroxaban, requiring immediate reporting.
Question 4 of 5
A child is brought to the emergency department after being bitten on the arm by a neighborhood dog. Which is the priority question for the nurse to ask the parent of the child?
Correct Answer: C
Rationale: When a bite occurs, the injury site of the bite should be cleansed carefully and the child should be given tetanus prophylaxis if immunizations are not up-to-date. The remaining options identify information that may have to be obtained, but are not the priority questions. Additionally the mother may not have the answers to these questions.
Question 5 of 5
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse administers regular insulin as ordered. When should the nurse expect the insulin to begin acting?
Correct Answer: A
Rationale: Regular insulin, a short-acting insulin, typically begins acting within 15 to 30 minutes after subcutaneous administration, making it effective for rapid blood glucose control.