NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which of the following should be the primary focus of nursing care for this client?
Correct Answer: C
Rationale: Thalassemia, a hemolytic anemia, causes increased cardiac workload due to chronic anemia and tissue hypoxia. Promoting rest is the primary focus to decrease cardiac demands and prevent complications like heart failure. While client preferences, nutrition, and emotional support are important, reducing cardiac strain is critical.
Question 2 of 5
A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. Which action should be the nurse's first response?
Correct Answer: B
Rationale: Macrocytic anemia, often due to vitamin B12 or folate deficiency, can cause peripheral neuropathy, leading to diminished sensations and increased risk of burns from prolonged heat exposure. The nurse's first action should be to check for sensory deficits to assess the underlying cause of the injury. Assessing for abuse, documenting, or dressing the wound are secondary actions.
Question 3 of 5
A client is scheduled for an elective splenectomy. Immediately before the client goes to surgery, the nurse should determine that the client has:
Correct Answer: B
Rationale: Verifying that the client has signed the consent form is the priority before surgery to ensure informed consent and legal compliance. Voiding, recording vital signs, and checking the name band are also important but secondary to consent verification.
Question 4 of 5
The nurse should teach the neutropenic client and the family to avoid which of the following?
Correct Answer: A
Rationale: Neutropenic clients should avoid suppositories or enemas, as they can cause rectal trauma and introduce infections. HEPA masks, perianal care, and oral care are recommended to reduce infection risk.
Question 5 of 5
The nurse is planning care with a client with acute leukemia who has mucositis. The nurse should advise the client that after every meal and every four hours while awake the client should use:
Correct Answer: C
Rationale: Mucositis in leukemia clients requires gentle oral care to prevent infection and promote healing. Saline or baking soda solution is soothing and non-irritating. Lemon-glycerin swabs can dry the mucosa, commercial mouthwash may irritate, and brushing may cause trauma.