NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
A client has vertigo. Which of the following actions would be most appropriate for the nursing diagnosis of Risk for injury related to altered immobility and gait disturbances? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Appropriate actions include assuming a safe position (e.g., sitting or lying down), preventing falls, performing vestibular exercises to improve balance, and keeping the head still during vertigo to minimize symptoms and reduce injury risk.
Question 2 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 3 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 4 of 5
A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to:
Correct Answer: D
Rationale: Tracheotomy equipment is essential due to the risk of airway obstruction from swelling or hemorrhage post-thyroidectomy.
Question 5 of 5
A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal to address for the client is:
Correct Answer: A
Rationale: In hospice care for advanced Hodgkin's disease, the primary goal is to address fear of pain, ensuring comfort as death approaches. Fear of therapy, isolation, and social inadequacy are less relevant at this stage.