NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
Which of the following measures should be implemented promptly after a client's nasogastric (NG) tube has been removed?
Correct Answer: A
Rationale: Oral hygiene removes residual tube-related irritation and promotes comfort after NG tube removal.
Question 2 of 5
The client has been prescribed lisinopril (Prinivil) to treat hypertension. The nurse should assess the client for which of the following electrolyte imbalances?
Correct Answer: A
Rationale: Lisinopril, an ACE inhibitor, can cause hyponatremia due to its effects on sodium excretion. Hypocalcemia and hypermagnesemia are not commonly associated with this medication.
Question 3 of 5
A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects?
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia, which requires monitoring and dental care. Weight gain, insomnia, and dry skin are not common side effects.
Question 4 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 5 of 5
A client who has a history of chronic ulcerative colitis is diagnosed with anemia. The nurse interprets that which factor is most likely responsible for the anemia?
Correct Answer: A
Rationale: The client with chronic ulcerative colitis is most likely anemic as a result of chronic blood loss in small amounts that occurs with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. There is no information in the question to support options 2 or 4. In ulcerative colitis, the large intestine is involved, not the small intestine, where vitamin B12 and folic acid are absorbed.