Questions 108

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Med Surg Questions Questions

Question 1 of 5

A client with rheumatoid arthritis states, 'I can't do my household chores without becoming tired. My knees hurt whenever I walk.' Which nursing diagnosis would be most appropriate?

Correct Answer: A

Rationale: The client's symptoms of fatigue and knee pain directly contribute to activity intolerance, making this the most appropriate nursing diagnosis.

Question 2 of 5

A client with an ileal conduit has a rash around the stoma. The nurse should:

Correct Answer: B

Rationale: Cleaning with soap and water removes irritants, promoting rash healing.

Question 3 of 5

A client with acute renal failure has edema. The nurse should:

Correct Answer: B

Rationale: Fluid restriction helps manage edema in acute renal failure.

Question 4 of 5

A nurse is making follow-up phone calls to clients being treated for cancer. Place the options below in the order of priority that the nurse should return the calls.

Order the Items

Source Container

The client receiving chemotherapy who complains of a loss of appetite.
The client who underwent a mastectomy 2 weeks ago who called for information on the Reach for Recovery program.
The client receiving spinal radiation for bone cancer metastases who complains of urinary incontinence.
The client with colon cancer who has questions about a high-fiber diet.

Correct Answer: C,A,B,D

Rationale: Urinary incontinence (
C) may indicate a serious complication like spinal cord compression, requiring immediate attention. Loss of appetite (
A) during chemotherapy can lead to malnutrition, followed by the mastectomy client's support needs (
B), and then dietary questions (
D).

Question 5 of 5

During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change to white in the fingers. The nurse should first assess:

Correct Answer: B

Rationale: A sudden color change to white in Raynaud's indicates vasospasm. Assessing the radial pulse first confirms whether blood flow is present despite the vasospasm, guiding further action. Cyanosis, SpO2, and blood pressure are secondary, as pulse assessment is more immediate and specific.

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