NCLEX-RN
Med Surg RN NCLEX Questions Questions
Extract:
Question 1 of 5
A client returned home from an overseas tour of duty and tells the nurse he is always tired. He has a temperature of 99.5°F (37.5°C). His skin is dark bronze, and his urine has a dark color. His hemoglobin level is 9 g/dL; his hematocrit is 49, and red blood cells are 2.75 million/µL. What should the nurse do first?
Correct Answer: B
Rationale: The client's symptoms (fatigue, bronze skin, dark urine, low hemoglobin, and RBC count) suggest hemolytic anemia, possibly due to an infectious or toxic exposure overseas. Placing the client on bed rest is the priority to reduce oxygen demand and prevent further hemolysis while diagnostic evaluation proceeds. Intake/output monitoring, isolation, and sunlight avoidance are not immediate priorities.
Question 2 of 5
Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to:
Correct Answer: B
Rationale: Older adults have reduced pressure sensation due to thinner skin and nerve changes, increasing the risk of skin breakdown and pressure ulcers.
Question 3 of 5
In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because?
Correct Answer: A
Rationale: A pre-stroke functional status history guides the rehabilitation plan by setting realistic goals based on prior abilities. Predicting outcomes, recognizing limitations, or expecting full recovery are secondary or unrealistic.
Question 4 of 5
A client is being prepared to have a craniotomy for a brain tumor. As a client advocate, the nurse is evaluating the client's understanding of the informed consent before witnessing the client's signature on the operative consent form. Which of the following indicates that the nurse needs to contact the surgeon for further communication with the client?
Correct Answer: C
Rationale: Stating there are no major risks indicates a misunderstanding, as craniotomy carries significant risks (e.g., bleeding, infection). The nurse must contact the surgeon to clarify risks for informed consent.
Question 5 of 5
The physician orders Morphine Sulfate 2-4 mg IV push every 2 hours prn pain for a client who has postoperative pain following abdominal surgery. Prior to performing an abdominal dressing change with packing at 10 AM, the nurse assesses the client's pain level as 1 on a scale of 0 = no pain to 10 = the worst pain. The client is awake and oriented and vital signs are within normal limits. The nurse reviews the pain medication record (see chart). The nurse should:
Correct Answer: A
Rationale: With a pain level of 1, the client does not require morphine (prn order). Performing the dressing change is appropriate, as the pain is minimal and manageable.