Questions 108

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Medical Surgical Questions and Answers Questions

Extract:


Question 1 of 5

A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following?

Correct Answer: D

Rationale: Sudden, sharp midepigastric pain with a rigid, boardlike abdomen strongly suggests ulcer perforation, a life-threatening complication requiring urgent intervention. The other options do not align with these clinical manifestations.

Question 2 of 5

A nurse is assessing a 42-year-old client who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm³ and has petechiae on the lower extremities. The nurse should advise the client to:

Correct Answer: D

Rationale: A platelet count of 22,000/mm³ with petechiae indicates severe thrombocytopenia, requiring urgent consultation with the oncologist for potential platelet transfusion or treatment adjustment.

Question 3 of 5

Which of the following would be a significant intervention to help prevent lung cancer?

Correct Answer: B

Rationale: Smoking cessation is the most effective intervention to prevent lung cancer, as smoking is the leading cause. Screening (not 'access to drugs'), asbestos checks, and air cleaners are less impactful.

Question 4 of 5

The nurse is caring for a client with a new colostomy and notices the client is reluctant to participate in self-care. Which intervention should the nurse implement first?

Correct Answer: C

Rationale: Assessing the client's barriers to self-care is the first step to understand and address their reluctance, enabling tailored interventions. Teaching family, referring to a support group, or providing instructions are secondary after identifying the underlying issues. CN: Psychosocial adaptation; CL: Synthesize

Question 5 of 5

A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:

Correct Answer: D

Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.

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