NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client’s body. Using the “rule of nines,” the nurse would determine that about what percentage of the client’s body surface has been burned?
Correct Answer: C
Rationale: According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.
Question 2 of 5
A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client?
Correct Answer: D
Rationale: Severe pain from renal colic is the priority, requiring opioid analgesics for immediate relief to improve client comfort and cooperation.
Question 3 of 5
Which of the following assessments should be a priority immediately after nasal surgery?
Correct Answer: C
Rationale: Respiratory status is the priority post-nasal surgery due to the risk of airway obstruction from packing or swelling. Pain, ecchymosis, and fluid balance are important but secondary to airway patency.
Question 4 of 5
The client with colon cancer has an abdominal-perineal resection with a colostomy. Which of the following nursing interventions is most appropriate for this client in the postoperative period?
Correct Answer: B
Rationale: Appropriate nursing interventions after an abdominal-perineal resection with a colostomy include assisting the client with warm sitz baths three to four times a day to clean the perineal incision. The client will be more comfortable assuming a side-lying position because of the perineal incision. It would be inappropriate to administer milk of magnesia to stimulate colostomy activity. Stool passage will begin as peristalsis returns. It is not necessary to be available to change the ostomy pouch to assess the stoma. The ostomy pouch should be transparent to allow easy observation of the stoma and drainage. CN: Physiological adaptation; CL: Synthesize
Question 5 of 5
An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Victims with chemical burns, third-degree burns, respiratory distress, or smoke inhalation require specialized care at a burn center due to the severity and potential complications of these injuries.