NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
The nursing assessment of a client with osteomyelitis of the left great toe reveals pain with partial weight-bearing, unsteady gait, and fever. The priority nursing diagnosis for the client is:
Correct Answer: D
Rationale: Risk for injury is the priority due to unsteady gait and pain, which increase the likelihood of falls in a client with osteomyelitis.
Question 2 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 3 of 5
A child with a diagnosis of sickle cell disease is admitted to the hospital for treatment of vaso-occlusive pain crisis. The nurse should plan for which interventions in the care of the client? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Management of the severe pain that occurs with vaso-occlusive crisis includes frequent pain assessment and the use of strong opioid analgesics, such as morphine sulfate and hydromorphone. Fluids are necessary to promote hydration, so options related to the delivery of fluids are appropriate. Oxygen is administered to increase tissue perfusion. Meperidine is contraindicated because of its side effects and increased risk of seizures after as few as 2 doses.
Question 4 of 5
A client who is brought to the emergency department has experienced a burn covering greater than 25% of his total body surface area (TBSA). When reviewing the laboratory results drawn on the client, which value should the nurse most likely expect to note?
Correct Answer: A
Rationale: Extensive burns covering greater than 25% of the TBSA result in generalized body edema in both burned and nonburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels elevate in the first 24 hours after injury (the emergent phase) as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit is 42 to 52% (0.42-0.52) in the male and 37 to 47% (0.37-0.47) in the female. The normal albumin is 3.5-5 g/dL (35-50 g/L). The normal sodium level is 135 to 145 mEq/L (135-145 mmol/L). The normal WBC count is 5000 to 10,000 mm^3 (5-10 x 10^9/L).
Question 5 of 5
The nurse is teaching a client with asthma about the use of a peak flow meter. Which of the following instructions should be included?
Correct Answer: B, C
Rationale: Recording the highest of three readings ensures accuracy, and cleaning the meter weekly prevents contamination.