NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
To reduce the risk of pressure ulcer formation, which of the following activities should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?
Correct Answer: C
Rationale: Shifting weight every 15 minutes relieves pressure on bony prominences, reducing pressure ulcer risk. The other options are less directly related to prevention.
Question 2 of 5
Which adverse effect of heparin sodium therapy, delivered continuously by intravenous infusion, should the nurse monitor the client for?
Correct Answer: B
Rationale: Heparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The remaining options are not related side or adverse effects of this medication.
Question 3 of 5
The mother of a child with newly diagnosed Duchenne's muscular dystrophy asks how her child developed the disease. The nurse formulates a response incorporating which of the following statements about its transmission?
Correct Answer: D
Rationale: Duchenne's muscular dystrophy is an X-linked recessive disorder, typically carried by females and transmitted to male children, who are more likely to express the disease.
Question 4 of 5
A client with a history of liver failure is admitted with hepatic encephalopathy. The nurse should monitor the client for which of the following?
Correct Answer: A
Rationale: Asterixis (flapping tremor) is a hallmark sign of hepatic encephalopathy due to ammonia buildup.
Question 5 of 5
As you are assessing the fetus during labor you are determining and the fetal lie, presentation, attitude, station and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?
Correct Answer: D
Rationale: Fetal station refers to the level of the fetus's presenting part relative to the mother's ischial spines, measured in centimeters above or below the spines. This is the correct definition among the options provided.