NCLEX-RN
Med Surg RN NCLEX Questions Questions
Extract:
Question 1 of 5
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should:
Correct Answer: B
Rationale: Cluster breathing, a sign of neurological deterioration, requires immediate physician notification for evaluation and possible intervention. Adjusting ventilator settings without medical orders is inappropriate, and simply counting the rate does not address the underlying issue.
Question 2 of 5
On the fourth day after surgery, a client has a postoperative wound infection. Which of the following should the nurse assess? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Signs of wound infection include redness/swelling (
B), fever (
C), pain (
D), and warmth (E). A WBC of 10,000/mm³ (
A) is normal and not indicative of infection.
Question 3 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.
Question 4 of 5
A client with diverticular disease is receiving psyllium hydrophilic mucilloid (Metamucil). The drug has been effective when the client tells the nurse that he:
Correct Answer: A
Rationale: Psyllium (Metamucil) is effective when the client passes stool without cramping, indicating improved bowel regularity and reduced irritation. Absence of diarrhea, anxiety, or gas are not primary indicators of its effectiveness. CN: Pharmacological and parenteral therapies; CL: Evaluate
Question 5 of 5
Which of the following actions should the nurse plan to do first when caring for a client who is experiencing spiritual distress?
Correct Answer: D
Rationale: Helping the client explore their own values and beliefs is the first step in addressing spiritual distress, as it establishes a foundation for personalized spiritual support.