NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 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 2 of 5
The nurse is preparing to care for a client who has undergone esophagogastroduodenoscopy (EGD). After checking the vital signs, what should be the nurse's next priority?
Correct Answer: C
Rationale: The nurse places highest priority on assessing for the return of the gag reflex, which is part of maintaining the client's airway. The nurse should also monitor the client for sharp pain (may indicate a potential complication) and heartburn. The client would receive warm gargles, but this cannot be done until the gag reflex has returned.
Question 3 of 5
Number the priority of the following conditions using the numbers # 1 through # 6 with # 1 as the greatest priority and # 6 as the least priority. 1. Atrial fibrillation 2. First degree heart block 3. Shortness of breath upon exertion 4. An obstructed airway 5. Fluid needs 6. Respect and esteem by others
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework and Maslow's hierarchy, the correct order is: An obstructed airway (4, #1, life-threatening), Shortness of breath upon exertion (3, #2, breathing issue), Fluid needs (5, #3, physiological need), Atrial fibrillation (1, #4, potential circulatory issue), First degree heart block (2, #5, often asymptomatic), Respect and esteem by others (6, #6, psychological need). Thus, B (3,4,5,1,2,6) is correct.
Question 4 of 5
A client with chronic kidney disease is on a low-potassium diet. Which food should the nurse advise the client to avoid?
Correct Answer: B
Rationale: Bananas are high in potassium, which must be limited in chronic kidney disease to prevent hyperkalemia.
Question 5 of 5
A child diagnosed with tinea is being treated with griseofulvin (Grifulvin V). Which of the following instructions should the nurse give to the parents?
Correct Answer: B
Rationale: Griseofulvin increases photosensitivity, so avoiding intense sunlight is critical. It is typically taken with food, requires weeks of treatment, and fluid intake is not specifically needed.