NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? Select all that apply.
Correct Answer: B,D,E
Rationale: Rifampin requires liver enzyme monitoring (
B) and alcohol avoidance (
D) due to hepatotoxicity risk. Orange urine (E) is a harmless side effect. Eye exams and reduced protein intake are not indicated.
Question 2 of 5
Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of myocardial infarction?
Correct Answer: B
Rationale: Small, easily digested meals reduce the metabolic demand on the heart and prevent gastrointestinal distress, which could exacerbate myocardial oxygen demand during the acute phase of MI.
Question 3 of 5
The nurse is caring for a client who is using a portable wound suction unit (see figure). Six hours following surgery, the drainage unit is full. The nurse should do which of the following?
Correct Answer: C
Rationale: Portable wound suction units can be emptied and drained. The nurse should compress the unit after emptying to create suction before reinserting the plug. It is normal for the suction unit to be full six hours after surgery, and the nurse does not need to notify the surgeon. The drainage unit should be emptied when full or every 8 hours. The drain in the incision should remain in place until the surgeon removes it. While all drainage should be noted as output on the chart, recording the amount without emptying the drainage unit is not accurate nor is it safe practice.
Question 4 of 5
To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, the nurse should instruct the client to:
Correct Answer: A
Rationale: Saline mouth rinses are gentle and safe post-transsphenoidal hypophysectomy, avoiding irritation to the surgical site.
Question 5 of 5
What action should this nurse take to avoid spreading nosocomial infections?
Correct Answer: C
Rationale: Hand hygiene is critical to prevent nosocomial infections. Washing hands before handling the mask ensures the nurse does not contaminate it or transfer pathogens. Removing protective gear or tying strings improperly could increase infection risk.