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
The nurse should instruct a client who is taking dexamethasone (Decadron) and furosemide (Lasix) to report:
Correct Answer: B
Rationale: Muscle weakness is a serious side effect of dexamethasone (steroid-induced myopathy) and furosemide (potassium loss), requiring prompt reporting.
Question 3 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 4 of 5
Which of the following would be true regarding medication reconciliation? Select all that apply.
Correct Answer: A, B, D
Rationale: Medication reconciliation is a Joint Commission goal to ensure accurate medication lists across care transitions. Equivalent medications are reconciled, but not all staff are limited to nurses/providers, and not all medications are physician-ordered.
Question 5 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.