NCLEX-RN
NCLEX RN Questions Medical Surgical Nursing Questions
Extract:
Question 1 of 5
A 10-year-old client is diagnosed with infectious mononucleosis. Her white blood cell (WBC) count is 19,000/µL. She has a streptococcal throat infection and her spleen is enlarged. She has aching muscles. Which of the following instructions should the nurse include in discharge planning with the client and the essential caregiver? Select all that apply.
Correct Answer: B,C,E
Rationale: Infectious mononucleosis with an enlarged spleen requires avoiding contact sports to prevent splenic rupture, a serious complication. Gargling with warm saline soothes the throat, and increased fluids support recovery and prevent dehydration. Bed rest is not strictly necessary unless fever persists, and aspirin should be avoided in children due to the risk of Reye's syndrome.
Question 2 of 5
Which of the following statements should the nurse include in the teaching session when preparing a client for arthrocentesis? Select all that apply.
Correct Answer: A,B
Rationale: Arthrocentesis involves using a needle and syringe to withdraw fluid, often with a local anesthetic for comfort. The procedure may be painful, and rest, not activity, is typically recommended post-procedure. A compression bandage is not standard.
Question 3 of 5
A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should:
Correct Answer: A
Rationale: Increased respiratory effort, rate, and pulse suggest a possible obstruction; checking for kinked or compressed tubing is the first step. Increasing suction, lowering bottles, or clamping tubes risks worsening the issue.
Question 4 of 5
The nurse is assessing a client with a casted arm for signs of infection. Which finding is most concerning?
Correct Answer: B
Rationale: A foul odor from the cast suggests infection, requiring immediate evaluation.
Question 5 of 5
Interferon alfa-2b (Intron A) has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which of the following adverse effects?
Correct Answer: C
Rationale: Interferon alfa-2b commonly causes flulike symptoms (
C), such as fever, chills, and fatigue, which are expected adverse effects. Retinopathy (
A), constipation (
B), and hypoglycemia (
D) are not typically associated with this medication.