NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
Your client has an allergy to both penicillin and latex. Which of these pathophysiological facts should you apply when you are providing to this client?
Correct Answer: A
Rationale: A sensitizing dose of penicillin can lead to anaphylaxis , a life-threatening allergic reaction, which is critical to consider when caring for a client with a penicillin allergy. The prevalence of dual allergies (C,
D) is not accurate, and distributive shock is not specific to a second dose.
Question 2 of 5
For which of the following should the nurse be especially alert when caring for a term neonate, who weighed 10 lb at birth, 1 hour after a vaginal delivery?
Correct Answer: A
Rationale: The neonate would be considered large for gestational age (LG
A) because the neonate weighs more than 4,000 g (90th percentile). Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other complications like hyperbilirubinemia may occur, but hypoglycemia is the priority concern within the first hour.
Question 3 of 5
The nurse is preparing to assess a client admitted with a diagnosis of trigeminal neuralgia (tic douloureux). On review of the client's record, which symptom should the nurse expect the client is experiencing?
Correct Answer: C
Rationale: Trigeminal neuralgia is a chronic syndrome characterized by an abrupt onset of pain. It involves one or more divisions of the trigeminal nerve (cranial nerve V). The remaining options are incorrect.
Question 4 of 5
A client diagnosed with valvular heart disease is at risk for developing heart failure. What should the nurse assess as the priority when monitoring for heart failure?
Correct Answer: B
Rationale: Breath sounds are the best way to assess for the onset of heart failure. The presence of crackles or an increase in crackles is an indicator of fluid in the lungs caused by heart failure. The remaining options are components of the assessment but are less reliable indicators of heart failure.
Question 5 of 5
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse administers regular insulin as ordered. When should the nurse expect the insulin to begin acting?
Correct Answer: A
Rationale: Regular insulin, a short-acting insulin, typically begins acting within 15 to 30 minutes after subcutaneous administration, making it effective for rapid blood glucose control.