NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 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 2 of 5
The nurse is caring for a client with a history of multiple sclerosis. Which of the following interventions should be included in the plan of care?
Correct Answer: A
Rationale: Daily exercise helps maintain mobility and strength in multiple sclerosis.
Question 3 of 5
As the registered nurse in the emergency department, you are taking care of an adolescent client who had just fractured their femur during gymnasium class at their high school. After casting, you will be discharging the client with crutches. Which of the following client goals that is paired with its learning domain should be included in the patient teaching plan for this client and the parents?
Correct Answer: A
Rationale: Proper crutch use involves psychomotor skills, such as slightly bending the elbows when holding the hand grips, to ensure safe and effective mobility.
Question 4 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 5 of 5
The nurse teaches the client diagnosed with acute gouty arthritis about the prescribed indomethacin therapy. The nurse determines that there is a need for further teaching when the client makes which statement?
Correct Answer: C
Rationale: Indomethacin may alleviate pain but is administered on a scheduled time frame, not on an as-needed schedule. Rest can be effective to relieve gouty arthritis pain. A rash could indicate hypersensitivity to the medication. The client should be instructed to monitor for swelling and gastric distress, which can be caused by the medication.