NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
Which is an intrinsic risk factor that places the client at risk for pressure ulcers?
Correct Answer: C
Rationale: Impaired tissue perfusion is an intrinsic risk factor for pressure ulcers, as it reduces oxygen and nutrient delivery to tissues, increasing susceptibility to breakdown.
Question 2 of 5
Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify that the client: Select all that apply.
Correct Answer: C, D
Rationale: t-PA requires normal blood pressure and no active bleeding to minimize complications like hemorrhage.
Question 3 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.
Question 4 of 5
The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:
Correct Answer: C
Rationale: The thalamus regulates body temperature, so an injury may impair thermoregulation. Monitoring bathwater temperature prevents burns or discomfort. Pain medication, eye patches, or avoiding movement are not directly related to thalamic injury.
Question 5 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.