NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client?
Correct Answer: C
Rationale: A multi-lumen tunneled and cuffed central venous catheter is ideal for long-term therapy due to its durability and lower infection risk.
Question 2 of 5
A client with a history of gastroesophageal reflux disease (GERD) is admitted with chest pain. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: Chest pain in GERD may mimic cardiac pain, so obtaining a 12-lead ECG rules out myocardial infarction.
Question 3 of 5
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse should expect to observe which of the following symptoms?
Correct Answer: B
Rationale: A high-pitched cry is a common symptom of bacterial meningitis in infants, indicating neurological irritation.
Question 4 of 5
The nurse reviewing a urinalysis report for a client with the diagnosis of acute kidney injury notes that the results are highly positive for proteinuria. The nurse determines that this client has which type of renal failure?
Correct Answer: C
Rationale: With intrinsic (intrarenal) renal failure, there is a fixed specific gravity and the urine tests positive for proteinuria. In prerenal failure, the specific gravity is high, and there is very little or no proteinuria. In postrenal failure, there is a fixed specific gravity and little or no proteinuria. There is no such classification as atypical renal failure.
Question 5 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.