NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
A client refuses to look at or care for her colostomy. Which of the following statements by the nurse would be most appropriate?
Correct Answer: D
Rationale: It is important for the nurse to recognize that individuals go through a grieving process when adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to care for the colostomy is not productive, nor is attempting to shame her into caring for the colostomy by implying her husband will have to provide the care if she does not. It is not possible for the nurse to understand what the client is feeling. CN: Psychosocial adaptation; CL: Synthesize
Question 2 of 5
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
Correct Answer: C
Rationale: Crohn's disease with diarrhea can lead to hypokalemia due to potassium loss in stool. Hyperalbuminemia and hypercalcemia are not typical, and thrombocytopenia is less directly related to these symptoms. CN: Physiological adaptation; CL: Analyze
Question 3 of 5
The client asks the nurse, 'Is it really possible to lead a normal life with an ileostomy?' Which action by the nurse would be the most effective to address this question?
Correct Answer: C
Rationale: Arranging for a person with an ostomy to visit provides a relatable, firsthand perspective, addressing the client's concerns about normalcy effectively. Clergy, postponing concerns, or notifying the surgeon are less direct or supportive. CN: Psychosocial adaptation; CL: Synthesize
Question 4 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 5 of 5
A client with ulcerative colitis is prescribed mesalamine (Asacol). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: C
Rationale: Worsening diarrhea in a client with ulcerative colitis taking mesalamine may indicate a lack of therapeutic response or a serious adverse effect, requiring immediate reporting. Mild headache, slight rash, and fatigue are less urgent but should be monitored. CN: Pharmacological and parenteral therapies; CL: Synthesize