NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed to avoid wrong-site surgery? Select all that apply.
Correct Answer: A,B,C,D
Rationale:
To prevent wrong-site surgery, the surgeon marks the site (
A), the client verifies identity and procedure (
B), records are checked (
C), and a time-out confirms the site (
D). Showing a model (E) is educational but not a standard safety measure.
Question 2 of 5
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition?
Correct Answer: A,B,C,D
Rationale: All listed changes are critical signs of increasing ICP. Widening pulse pressure (Cushing's triad), bradycardia, dilated fixed pupils, and decreased LOC indicate neurological deterioration requiring immediate notification of the health care provider for intervention.
Question 3 of 5
The nurse is assessing a client with hepatitis and notices that the AST and ALT levels have increased. Which of the following statements by the client requires further instruction by the nurse?
Correct Answer: D
Rationale: Acetaminophen (
D) is hepatotoxic and should be avoided in hepatitis due to increased liver enzyme levels. Rest (
A), a low-fat, high-carbohydrate diet (
B), and dry toast for nausea (
C) are appropriate.
Question 4 of 5
A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following?
Correct Answer: B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, requiring physician notification. A respiratory rate >16 is normal. Fluid in the tube and fluctuation are expected.
Question 5 of 5
A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by:
Correct Answer: A
Rationale: An arteriogram involves injecting contrast dye to visualize arteries, revealing the location of obstructions and collateral circulation in occlusive arterial disease. It is a direct imaging method, unlike ultrasound (velocity changes) or volume scans, and walking duration is not assessed.