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NCLEX RN Med Surg Questions Questions

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Question 1 of 5

A client is undergoing a bone marrow aspiration and biopsy. What is the best way for the nurse to help the client handle her stress?

Correct Answer: C

Rationale: Encouraging slow, deep breaths helps reduce anxiety and promotes relaxation during the stressful bone marrow aspiration procedure. Family presence, hand-holding, and expressing feelings are supportive but less effective for immediate stress management.

Question 2 of 5

A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply.

Correct Answer: B,C

Rationale: In peritonitis, the nurse should percuss the liver for lack of dullness (
B), indicating free air, and monitor vital signs for fever, tachypnea, and tachycardia (not bradycardia) (
C). Resonance and tympany, polyphagia, polydipsia, and bowel sound frequency are less specific for peritonitis. CN: Physiological adaptation; CL: Analyze

Question 3 of 5

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?

Correct Answer: C

Rationale: Monitoring temperature every 15 minutes during active rewarming ensures timely detection of hypothermia resolution or hyperthermia, balancing safety and practicality.

Question 4 of 5

A client is receiving an I.V. infusion of 5% dextrose in water (D5W). The skin around the I.V. insertion site is red, warm to touch, and painful. The nurse should first:

Correct Answer: C

Rationale: Redness, warmth, and pain at the I.V. site indicate phlebitis or infiltration. The first action is to discontinue the I.V. to prevent further tissue damage. Changing fluids, applying a compress, or giving acetaminophen does not address the immediate issue.

Question 5 of 5

A nurse is making follow-up phone calls to clients being treated for cancer. Place the options below in the order of priority that the nurse should return the calls.

Order the Items

Source Container

The client receiving chemotherapy who complains of a loss of appetite.
The client who underwent a mastectomy 2 weeks ago who called for information on the Reach for Recovery program.
The client receiving spinal radiation for bone cancer metastases who complains of urinary incontinence.
The client with colon cancer who has questions about a high-fiber diet.

Correct Answer: C,A,B,D

Rationale: Urinary incontinence (
C) may indicate a serious complication like spinal cord compression, requiring immediate attention. Loss of appetite (
A) during chemotherapy can lead to malnutrition, followed by the mastectomy client's support needs (
B), and then dietary questions (
D).

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