NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
A client is in the acute phase of rheumatoid arthritis. Which of the following should the nurse identify as lowest priority in the plan of care?
Correct Answer: C
Rationale: During the acute phase, relieving pain, preserving joint function, and preventing deformity are critical to manage inflammation and prevent long-term damage. Maintaining usual ways of accomplishing tasks is less urgent.
Question 2 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 3 of 5
When teaching the diabetic client about foot care, the nurse should instruct the client to do which of the following?
Correct Answer: A
Rationale: Diabetic clients should avoid going barefoot to prevent foot injuries, which can lead to serious complications due to poor healing and neuropathy.
Question 4 of 5
The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate?
Correct Answer: D
Rationale: Jaundice (
D) is a common early sign of cirrhosis due to impaired bilirubin metabolism. Peripheral edema (
A) and ascites (
B) occur later. Anorexia (
C) is less specific.
Question 5 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.