Questions 108

NCLEX-RN

NCLEX-RN Test Bank

Med Surg RN NCLEX Questions Questions

Extract:


Question 1 of 5

A client who underwent a left lower lobectomy has been out of surgery for 48 hours. She is receiving morphine sulfate via a patient-controlled analgesia (PCA) system. She tells the nurse that she has some pain in her left thorax that worsens when she coughs. The nurse should:

Correct Answer: D

Rationale: A detailed pain assessment using a scale clarifies the pain's severity and guides adjustments to analgesia. Silencing the client or encouraging deep breaths may worsen pain. Checking the PCA is appropriate but secondary to assessment.

Question 2 of 5

What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?

Correct Answer: C

Rationale: Clear drainage from the nose after a head injury may indicate cerebrospinal fluid (CSF) leakage, a serious condition. The priority is to collect the fluid for analysis to confirm CSF and avoid infection, making providing tissues the first action. Compressing the nares or tilting the head back could increase intracranial pressure or contaminate the fluid, and an antihistamine is inappropriate without confirming the cause.

Question 3 of 5

The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of his fractured femur. Which of the following should the nurse do when transporting the client to the operating room?

Correct Answer: C

Rationale: Transporting on the bed with extra help maintains traction stability, preventing fracture displacement.

Question 4 of 5

The nurse teaches a client with chronic obstructive pulmonary disease for signs and symptoms of right-sided heart failure. Which of the following signs and symptoms should be included in the teaching plan?

Correct Answer: C

Rationale: Right-sided heart failure (cor pulmonale) in COPD causes peripheral edema due to increased venous pressure. Clubbing reflects chronic hypoxia, not heart failure. Hypertension and increased appetite are unrelated.

Question 5 of 5

In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain?

Correct Answer: B

Rationale: Intravenous opioids are preferred in the acute phase for rapid, effective pain relief due to severe burn pain and potential impaired oral absorption.

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