NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
The nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis?
Correct Answer: A
Rationale: A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle, which occurs in hydrocephalus. An elevated apical heart rate, proteinuria, and a drop in blood pressure are not specifically related to increasing cerebrospinal fluid in the brain tissue.
Question 2 of 5
A client with a history of stroke is at risk for aspiration. Which intervention is most appropriate?
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk by aiding swallowing and gravity.
Question 3 of 5
A client with a history of heart failure is prescribed valsartan (Diovan). The nurse should monitor the client for which of the following side effects?
Correct Answer: A
Rationale: Valsartan, an ARB, can cause hyperkalemia, requiring monitoring of potassium levels.
Question 4 of 5
A client who sustained a fractured leg has learned how to use crutches. The nurse should determine that the client has a need for further teaching if the client makes which statement about using crutches?
Correct Answer: D
Rationale: The client should use only crutches measured for the client. Crutches belonging to another person should not be used unless they have been adjusted to fit the client. Spare tips and crutches fitted to the client should be available if needed. Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The tips should be regularly inspected for wear.
Question 5 of 5
A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information?
Correct Answer: C
Rationale: Difficulty urinating can indicate herpes-related urinary retention, a serious complication requiring medical attention.