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
Which of the following is true with regard to delegation of client care responsibilities? Select all that apply.
Correct Answer: A, C, D, E
Rationale: Delegation involves understanding the care model, validating caregiver competency, determining tasks, and documenting delegation, but not delegating based solely on time demands.
Question 3 of 5
A primigravid client at 10 weeks' gestation tells the nurse that she eats fruits and vegetables but isn't fond of them. After teaching the client about possible serving sizes, the nurse determines that the teaching has been successful when the client states that one serving of fruit is equivalent to which of the following?
Correct Answer: A
Rationale: One serving of fruit is equivalent to one-fourth of a cantaloupe. The client needs $6 \mathrm{oz}$ of a vegetable juice cocktail, two tomatoes, or two raw apricots to meet one fruit serving.
Question 4 of 5
Which intervention would you expect to render to the client in a sickle cell anemia crisis?
Correct Answer: B
Rationale: Hydroxyurea is used in sickle cell anemia to reduce the frequency of crises by increasing fetal hemoglobin, which helps prevent sickling of red blood cells.
Question 5 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.