NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
A 75-year-old male client has a history of macular degeneration. While he is in the hospital, the priority nursing goal will be:
Correct Answer: C
Rationale: Promoting a safe, effective care environment is the priority to prevent falls and injuries due to impaired central vision in a hospital setting.
Question 2 of 5
The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (
A) is significant and may indicate worsening liver function or fluid loss, requiring urgent physician attention. Nausea (
B), low-grade fever (
C), and fatigue (
D) are common but less critical.
Question 3 of 5
The nurse uses a Doppler ultrasound device to assess the client's lower extremities. In addition, the nurse calculates the ankle-brachial index to estimate stenosis of the:
Correct Answer: A
Rationale: The ankle-brachial index (ABI) measures the ratio of ankle to brachial systolic blood pressure to assess arterial stenosis in the lower extremities. A low ABI indicates arterial narrowing, typical in PVD. It does not assess the aorta, carotid, or veins.
Question 4 of 5
To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, the nurse should instruct the client to:
Correct Answer: A
Rationale: Saline mouth rinses are gentle and safe post-transsphenoidal hypophysectomy, avoiding irritation to the surgical site.
Question 5 of 5
Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg?
Correct Answer: B
Rationale: Low-dose barbiturates can reduce cerebral metabolism and ICP, making them appropriate in some cases under medical supervision. Warming blankets increase metabolic demand, hyperventilation is no longer routinely recommended due to risks of cerebral vasoconstriction, and fluid restriction is not standard for ICP management unless specifically indicated.