NCLEX-RN
Med Surg RN NCLEX Questions Questions
Extract:
Question 1 of 5
A 66-year-old female who is usually meticulous about her appearance and dress arrives today for her 23rd day of radiation therapy and appears disheveled and emotionally labile, and her responses to the usual questions are a little inappropriate. Her heart rate is 124 bpm, her respirations are 32 breaths/minute, and her skin is cold and clammy. These findings would suggest that the nurse should further assess the client for which of the following conditions?
Correct Answer: D
Rationale: Disheveled appearance, emotional lability, inappropriate responses, and physical symptoms (tachycardia, tachypnea, clammy skin) suggest delirium, a medical emergency requiring urgent assessment.
Question 2 of 5
A client has returned to the medical surgical unit after having surgery to create an ileostomy. Which goal has the highest priority at this time?
Correct Answer: C
Rationale: Maintaining fluid and electrolyte balance is the highest priority post-ileostomy due to the risk of dehydration from high-output ileostomy effluent. Constipation is not a concern, and self-care or odor control are secondary to physiological stability. CN: Physiological adaptation; CL: Synthesize
Question 3 of 5
The nurse observes the client instill eyedrops. The client says, 'I just try to hit the middle of my eyeball so the drops don't run out of my eye.' The nurse explains to the client that this method may cause:
Correct Answer: A
Rationale: Instilling eyedrops directly onto the cornea (middle of the eyeball) can cause corneal abrasion due to the dropper tip or improper technique. Drops should be placed in the lower conjunctival sac.
Question 4 of 5
The client has a latex allergy. What should the nurse teach the client to do before having surgery at a free-standing surgery center? Select all that apply.
Correct Answer: A,B,C
Rationale: Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs/symptoms may be mild to anaphylaxis. Clients with latex allergy are advised to notify their health care providers and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current.
Question 5 of 5
A client with Cushing's disease tells the nurse that the physician said the morning serum cortisol level was within normal limits. The client asks, 'How can that be? I'm not imagining all these symptoms!' The nurse's response will be based on which of the following?
Correct Answer: C
Rationale: Cushing's disease disrupts the normal diurnal cortisol rhythm, leading to consistently high levels, which may not be captured in a single morning test.